Anxiety Disorders Toolkit Information and Resources for Effective Self-Management of Anxiety and Anxiety Disorders PILOT VERSION OCTOBER, 2003
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Anxiety Disorders Tool Kit: Information and Resources for Effective Self-Management of Anxiety and Anxiety Disorders \u00a9 2003, BC Partners for Mental Health and Addictions Information Prepared by Sarah Newth, PhD Anxiety Disorders Association of British Columbia Funded by the Ministry of Health Services, Province of British Columbia
The Mental Health and Addictions Information Plan for Mental Health Literacy is a groundbreaking public information initiative driven by the Anxiety Disorders Association of BC (ADABC), Awareness and Networking around Disordered Eating (ANAD), British Columbia Schizophrenia Society (BCSS), Canadian Mental Health Association BC Division (CMHA), Kaiser Foundation, the Mental Health Evaluation & Community Consultation Unit (Mheccu), and Mood Disorders Association of BC (MDA), working together in a collective known as the BC Partners for Mental Health and Addictions Information. The project is funded by the Ministry of Health Services, under the direction of Dr. Gulzar Cheema, Minister of State for Mental Health. Over three years, the project will create a permanent communications infrastructure, including a website and a series of practical toolkits developed to help individuals living with (or at risk for) mental health or substance use problems to manage their health conditions on a day-to-day basis. Combined, the groups have more than 100 years of service to British Columbians and regional branch networks or linkages throughout the province. www.heretohelp.bc.ca
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Table of Contents Introduction ......................................................................... 4What are effective ways of self-managing anxiety disorders? .... 29 Why do we need a tool kit for anxiety disorders? ............. 4 Educating & empowering self ........................................ 29 How do I use this tool kit? ............................................... 4 Managing bodily symptoms .......................................... 30 Disclaimer ....................................................................... 4 Healthythinkingpatterns .............................................. 32 Buildingstrengths:decreasingsafetyandavoidancebehaviours. 35 Relapse prevention ........................................................ 36 What is anxiety? ................................................................... 5 What are common symptoms of anxiety? ............................ 6 What can family and friends do to help? ............................. 38 Emotions (How we feel) .................................................. 6 Body responses (How our bodies react) ........................... 6What are problems that can coexist with an anxiety disorder? .. 40 Thoughts (What goes through our mind) ......................... 6 Behaviours (How we respond) ......................................... 6Where do I go to get more help? ......................................... 40 What are panic attacks? ........................................................ 7What are other useful resources for anxiety disorders? ........41 How is normal anxiety different from an anxiety disorder? .. 8 Concluding remarks ............................................................41 How common are anxiety disorders? ................................... 9 How do I give my feedback about this toolkit? .................... 42 How do I know if I have an anxiety disorder? ....................... 9 Appendix 1: Self-test for anxiety ......................................... 43 What do anxiety disorders all have in common? .................. 10 Appendix 2: Sources ........................................................... 46 How are anxiety disorders different from depression? ......... 11 How are anxiety disorders different from stress? ................ 12 What are risk factors for developing an anxiety disorder? ... 12 Genetic predisposition ................................................... 12 An existing anxiety disorder .......................................... 12 Perfectionism ................................................................ 12 Environmental factors ................................................... 12 What is panic disorder? ...................................................... 13 What is agoraphobia? ......................................................... 15 What is obsessive-compulsive disorder? ............................. 16 What is social anxiety disorder? ......................................... 18 What is generalized anxiety disorder? ................................ 19 What is post-traumatic stress disorder? ................................ 21 What are specific phobias? ................................................. 22 Why should I consider getting treatment ............................ 24 What should I tell my health professional ........................... 24 Anxiety symptoms checklist .......................................... 25 What are effective treatments for anxiety disorders ............ 26 Medications ................................................................... 26 Cognitive-behavioural programs .................................... 27 What should I know about alternative or complementary treatments for anxiety disorders? ....................................... 27 Are self-help groups useful? ................................................ 29
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Introduction
have more than one opportunity to absorb everything you need to know. Be kind to yourself if you are trying to overIf you are suffering from an anxiety disorder please know come the symptoms of an anxiety disorder. Change takes that you are not alone and there are strong reasons for time and most of us have to make repeated attempts before you to feel hope for the future. we experience the benefits of our efforts. It is normal to exAs you read through this tool kit you will learn the basic perience some difficulties understanding the information and facts about anxiety and anxiety disorders. You will also learnusing the recommended strategies. Most people coping with that it is possible to effectively manage and even overcome an anxiety disorder find they feel empowered and liberated the symptoms of anxiety disorders. by the types of information and strategies included in this tool kit – even if they felt a bit overwhelmed at first.
Why do we need a toolkit for anxiety disorders?
Should I consult other resources?
What is the purpose of the anxiety disorders toolkit?
For more information about how you can become a better judge of health research findings and for summaries of mental health topics (including anxiety disorders) especially written for consumer and families see www.cochraneconsumer.com.
Anxiety disorders are the number one mental health prob- Many people find they need to consult more than one relem among adults and children. Approximately 1 in 10 peoplesource to get all the different information they need and this suffer from an anxiety disorder and 1 in 4 of us will experi- toolkit is by no means exhaustive. We recommend you seek ence significant problems with anxiety at some point in our out additional resources. Information about anxiety disorders lives. This means that over 400,000 British Columbians are is available from a large variety of sources including the currently suffering from at least one anxiety disorder. Unfor- internet, books, television, newspapers, radio and magazines. tunately, the very nature of anxiety disorders means that Sometimes it can be overwhelming trying to make sense of many individuals and families suffer alone and in silence. it all. Be aware that some information is high quality but some Fortunately, there is good reason for people affected by anxi- information is actually incorrect or misleading. An imporety problems to have hope. With high quality information tant component of self-management is being able to evaluand resources, individuals with anxiety disorders can and do ate the quality of any piece of information so you are fully overcome their anxiety problems and go on to have fulfilling informed when making any decisions about your health, including managing anxiety disorders. and productive lives.
The purpose of this self-management tool kit is to provide British Columbians with top quality information that helps us identify and effectively manage problems due to anxiety To make it easier for people to access high quality resources disorders. How we cope with the symptoms of anxiety disor- we have listed useful books and websites for each topic inders on a daily basis plays a huge role in determining our cluded in the toolkit. Some of the resources only concern current and future symptoms. When a person is informed one particular anxiety disorder or one specific issue related and educated about their anxiety disorder(s) they are often to anxiety disorders. Other resources contain a whole range more able to keep the symptoms in check and keep the in- of information about more than one topic or more than one terference due to excessive anxiety to a minimum. Getting anxiety disorder. We have included all evidence based seleceducated and empowering ourselves by learning and prac- tions we are aware of for each topic but some topics have ticing helpful coping strategies is referred to as “self-man- more available resources than others. Focus on getting acagement”. To be successful at self-management people with cess to the recommended resources that are listed in the secan anxiety disorder need to be able to recognize their anxi- tions that are the most relevant to you. Try to read one reety symptoms when they occur. We also need a whole range source at a time so that you do not get overwhelmed. of additional information. To make self-management easier, this tool kit includes information about the characteristics of Disclaimer normal anxiety, the different types of anxiety disorders, efThe BC Partners for Mental Health and Addictions Informafective treatment options, and basic self-management strattion seek to provide people with reliable and practical inforegies that can help reduce symptoms of anxiety. Also included mation. Facts and findings from well-conducted studies have is information about other “easy to access” high quality rebeen summarized to present the best available material on sources. The tool kit will be most helpful for individuals coptopics of interest. Special attention is given to ensuring that ing with an anxiety disorder or problems with anxiety. Famsources are credible, accurate, current, and relevant. The ily, friends, health professionals, students and anyone who material is comprehensive, but it is not exhaustive and does wants to learn more about the most common type of mental not rule out numerous interventions that may be merited in health problem will also find this tool kit a helpful resource particular cases. Readers will also find that the information is This tool kit takes an “evidence based” approach. See Disnot a standard of care and does not stipulate a single correct claimer Below. approach for all situations. Decisions regarding specific interventions for individuals remain the responsibility of the How do I use this toolkit? individual person who has the illness in collabaration with There is a lot of information contained in this manual so take their health care professional and support network. The inyour time and read at your own pace. You can read any sec- formation provided through the BC Partners is intended for tion in any order. Reread sections that apply to you so you educational use and general information and is not intended 4
What is anxiety?
to provide, nor should it be considered to be a substitute for, professional medical advice or other professional services. When we feel threatened most of us will experience anxiPlease also note that some of the websites listed in this resource contain commercial products available for pur- ety or fear. Some experiences will trigger anxiety in most chase. We do not endorse any of these online products orof us (e.g., thinking about giving a talk to a large number of people or thinking a bear might be following you while services available for a fee. We have chosen to include such websites due to the high quality of free evidence-based walking in the forest). In our daily lives the things that make us feel anxiety can vary from person to person. For information and self-management programs also available. The very nature of this self-management tool kit means example, some people feel very anxious about snakes or spiders while others have them for pets. that cognitive behavioural strategies for anxiety disorders are emphasized over medications. Cognitive behavioural strate- When it comes to anxiety, ALL humans are naturally gies involve looking at how we think or what we believe (the programmed to react with the “fight-flight-freeze” re“cognitive” part) and examining our behaviours or coping sponse. Anxiety and the fight-flight-freeze response is a responses (the “behaviour part). Increasing healthy cogni- normal alarm reaction. We would not have survived as a tive behavioural strategies is an important component of ef- species if we did not have anxiety and the fight-flightfreeze response as it allows us to sense danger and react in fective self-management (see page 29). This by no means takes away from our endorsement of a way that keeps us safe. Anxiety causes changes in the select medications as evidence based treatments for anxietybody that increase our ability to: • defend ourselves against the source of danger (“fight”) disorders. Research clearly suggests that select medications • are just as effective as cognitive behavioural programs in the get away from something dangerous (“flight”) • remain still enough to avoid being detected by a source treatment of most anxiety disorders (see page 23). For this of danger (“freeze”) reason, medications are included in this tool kit as they can be an important component of effective self-management for some of the anxiety disorders. To go directly to the self-test to see if you may be suffering from an anxiety disorder you can jump ahead to page 32. Remember to go back and read the relevant sections that you have skipped.
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What are common symptoms of anxiety?
3) Thoughts (What goes through our mind)
When we feel anxious our patterns of thinking can change. We are more likely to notice and think about things related to real or potential sources of danger. The following are some Symptoms of anxiety can be broken down into four major common thinking patterns associated with anxiety: categories: • Frightening thoughts, images, urges or memories 1 emotions • Something bad happening to self (dying, not being able 2 body responses to cope, being responsible for something terrible happen3 thoughts ing, embarrassing ourselves, etc) 4 behaviours • Something bad happening to someone else (family member dying, a child being harmed, spouse having an acci1) Emotions (How we feel) dent, etc) The emotions associated with anxiety can also be described• Something else bad happening (house burning down, as feeling fearful, worried, tense, on guard, scared, apprepersonal possession being stolen, car crash, terrorist athensive, frightened, “freaked out”, etc. We usually know we tack, etc) are feeling the emotion of anxiety when we are also experi- • Increased attention and scanning for things related to the encing anxious body responses, thoughts, or behaviours. source of danger • Difficulty concentrating on things not related to the source of danger 2) Body responses (How our bodies react) • Anxiety can trigger a range of body responses involving blood Difficulty making decisions about other things flow, the heart, the lungs, muscles, vision, hearing, skin, hair, • Frightening dreams or nightmares digestion, saliva, and other body systems. Anxiety causes a range of physiological changes in the body that can lead to 4) Behaviours (How we respond) the following symptoms: Anxiety triggers a number of coping behaviours. Most of us • Rapid heart, heart palpitations, pounding heart will feel a strong urge to do things that eliminate the danger • Sweating or make us feel safer. These are referred to as “safety • Trembling or shaking behaviours” and common examples are listed below: • • Shortness of breath or smothering sensations Avoiding the feared situation, experience, place or people • • Dry mouth or feeling of choking Escaping or leaving the feared situation, experience, place • Chest pain or discomfort or people • • Nausea, stomach distress or gastrointestinal upset Needing to be with a person or pet who makes us feel safe • • Urge to urinate or defecate Getting reassurance from others • • Cold chills or hot flushes Telling ourselves reassuring things (e.g., “It will be ok”) • • Dizziness, unsteady feelings, lightheadedness, or faintness Finding a safe place to go to • Feelings of unreality or feeling detached from oneself • Scanning the situation for signs of danger • • Numbing or tingling sensations Trying to distract ourselves • • Visual changes (e.g., light seems too bright, spots, etc.) Self-medicating the symptoms with drugs, alcohol or food • Blushing or red blotchy skin (especially around face) • Sleeping or napping so we don’t have to think about it • Muscle tension, aches, twitching, weakness or heaviness • Carrying items that may prevent or help cope with a panic These symptoms of anxiety are uncomfortable but they are attack (e.g., medications, cell phone, vomit bag, etc). not dangerous (and can even be helpful). For example, our • Compulsive behaviours that we repeat in an attempt to hearts pump faster when we feel anxious to help us get more feel better (e.g., excessive cleaning or checking) blood to the muscles in our legs and arms that we need to • Mental rituals that we repeat in our minds in an attempt run away, fight or remain still until the danger passes. We to feel better (e.g., thinking the same word or phrase over might also feel dizzy or light-headed due to the sudden inand over) crease in blood oxygen that happens as the heart pumps These behaviours are only considered safety behaviours if faster – this is a harmless side effect of the anxiety response. the main purpose is to prevent or eliminate feelings of anxiSome people also feel nauseous because the body shuts downety or panic. If safety behaviours become frequent, compulour digestive system in the face of danger to save energy. sive and disruptive they tend to increase the severity of an The pupils in our eyes will often open up widely (allows us to anxiety disorder. Most of the safety behaviours are used with see better) and often leads to light sensitivity or seeing spots. good intentions. Unfortunately they usually backfire and make Each of the body symptoms listed above can be traced back the symptoms of anxiety worse in the long-term. For example to some kind of harmless or helpful change that is triggered many people with an anxiety disorder who take time off work by anxiety. often experience even higher levels of anxiety or end up on Note: The symptoms of anxiety do overlap with symp- disability when they avoid work. Safety or avoidance toms of some medical conditions. Always review any body behaviours do not empower people in their ability to cope symptoms of anxiety with your physician so that medical with anxiety symptoms. You don’t need to keep yourself safe conditions can be ruled out. from panic or anxiety by using safety or avoidance behaviours but you will never have a chance to find this out as long as you keep using them. 6
What are panic attacks?
People with anxiety disorders often experience huge benefits in their symptoms if they are able to gradually decrease their use of safety behaviours. Research has also shown that Sometimes the symptoms of anxiety (see page 4-6) can ocpeople who don’t give up this unhelpful way of coping have a cur very suddenly with high intensity resulting in a “panic higher rate of relapse compared to people who give up their attack”. Every year approximately 1 in 3 of us will experisafety behaviours. See page 34 for more information about ence a panic attack – a sudden rush of intense anxiety symphow to build strengths by decreasing safety behaviours and toms that reach their peak within a few minutes. Most panic attacks experienced by people are strong anxiety reactions to: overcoming avoidance. • anticipating something stressful (e.g., new job, medical Examples of Safety Behaviours (indicated by “SB”): procedures, etc.) Mark is a 32 year-old computer programmer with panic disor- • a stressful event (e.g., work deadline, relationship probder. His primary concern during a panic attack is that he is havlem, etc.) ing a heart attack or stroke (even though his physician has con-• experiences that cause physical symptoms (e.g., exercise, firmed he is in excellent health). Mark carries his cell phone on drinking coffee, using recreational drugs such as marihim at all times so he can call for help if needed (SB) and checks juana, etc.). frequently to see if it is in his pocket (SB). He often leaves enjoyMany people with anxiety disorders also experience panic able events if the phone battery runs out (SB), avoids busy suattacks. For example, individuals with obsessive-compulsive permarkets or busy bridges (SB) and has stopped doing anydisorder may experience panic attacks in response to upsetthing active that speeds up his heart rate (SB). Mark can’t help ting obsessions, or when their compulsions are interrupted. but wonder whether there are better ways to cope with his panic Individuals with social anxiety disorder may experience panic and anxiety problems. He is starting to realize that his safety attacks when thinking about a feared social situation, when behaviours are making his anxiety worse over time. See page 27 actually in the feared social situation, or when ruminating for Mark’s self-managament plan to overcome the safety about a past social experience they believe went badly. People behaviours associated with panic disorder. who suffer from generalized anxiety disorder may experience a panic attack when worrying excessively. People with specific phobias (e.g., excessive fear of dogs, storms, heights, etc.) can experience panic attacks when facing their fears either in their thoughts or during actual experiences. Individuals with post- traumatic stress disorder or acute stress disorder may experience panic attacks when thinking about the trauma and its aftermath. Individuals with agoraphobia may experience panic attacks in feared situations such as when leaving their home. For individuals with panic disorder it is excessive fear of the panic attacks themselves that becomes the problem. (For more information about these specific types of anxiety disorders see page 13). Most people who have panic attacks as part of their anxiety disorder find that the attacks lessen or stop after receiving effective treatment. How do I cope with a panic attack? If you experience a panic attack (whether you have an anxiety disorder or not) try to remind yourself that the symptoms of a panic attack are uncomfortable symptoms of anxiety but they are not dangerous. A panic attack is NOT a sign that you are going to die, go crazy or lose control of yourself in some other way (see page 6) for more information about anxiety symptoms. See pages 14, 29 and 40 for more resources on coping with anxiety and panic attacks.
Examples of panic attacks not associated with an anxiety disorder •
In early December, Marcello realized that he and would not be able to afford many Christmas presents for the children due to excessive credit card debt. While reviewing the situation with his wife he became very upset that the children might be disappointed and he experienced a panic attack triggered by the stress of it all. The symptoms lasted for about 10 minutes at their peak intensity including rapid heart beat, sweating, and feelings of unreality. He felt quite tense and jittery for about 7
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How is normal anxiety different from an anxiety disorder?
an hour but has had no other major problems with anxiety recently. Several months ago Charlotte’s elderly mother was diagnosed with cancer. When thinking about all the different issues that needed attention and the responsibility of All of us experience anxiety from time to time. Individuals caring for her ill mother Charlotte experienced a panic with an anxiety disorder experience excessive symptoms of attack. The symptoms lasted for about 5 minutes at theiranxiety and associated symptoms on a regular basis for a peak intensity including dizziness, tingling in her fingersprolonged period of time (months and years rather than just and shortness of breath. Charlotte was also very tearful a few days or weeks). for about 30 minutes while she talked with her husband. She does not have an anxiety disorder but is experienc- When is it a problem? ing some of the normal anxiety symptoms associated Assessment for an anxiety disorder should be considered under the following circumstances: with care-giving for an ill loved one. Symptoms of anxiety and associated problems…. While writing an important professional certification • have been excessive and difficult to control for an extended exam Jake felt a sudden surge of anxiety symptoms and period of time (more than just a few days or weeks) experienced a panic attack when thinking about the pos• lead to significant emotional distress and personal suffersibility of failing. Although he did not leave the room he ing experienced intense panic symptoms for several min• lead to significant interference in work, school, home or utes that made it difficult to concentrate. Eventually his social activities heart beat slowed down, the visual spots disappeared, his hands stopped shaking and the urge to leave the roomSometimes the symptoms of an anxiety disorder are present went away. He does not have an anxiety disorder and most or all of the time. Sometimes the symptoms are only Jake does not avoid these situations even when they makepresent when facing certain situations, places, experiences or people. It is also common for symptoms of an anxiety him feel a bit anxious or panicky. disorder to go up and down over time – people with an anxiety disorder often find that their symptoms get worse when they are under stress or feeling depressed.
How common are anxiety disorders?
How do I know if I have an anxiety disorder?
Many people are unaware that anxiety disorders are the most You should be assessed for an anxiety disorder if you common type of mental health problem. Approximately 1 in experience ongoing or excessive symptoms of anxiety (see 10 people currently have an anxiety disorder and approxi- page 6) that lead to significant distress or significant intermately 1 in 4 people will experience significant problems ference in your work, school, home or personal life. Somewith anxiety at some point in their lives. times people are unaware that their responses to situations are the symptoms of an anxiety disorder. For anare interactive on-line self-test for anxiety disorders • It is estimated that over 400,000 British Columbians currently suffering from an anxiety disorder. (and depression) see the following website: • over 295,000 adults suffer from a mild anxiety disorder www.freedomfromfear.org/screenrm.asp • over 70,000 adults suffer from a chronic anxiety disorder This online self-test is provided by a US consumer (symptoms present for at least one year with significant oriented organization called “Freedom From Fear”. distress and interference in functioning) A printable self-test is also available at the ADABC • over 38,000 adults suffer from a serious anxiety disorder website (www.anxietybc.com). Alternatively you can (severe symptoms associated with significant disability) complete the self-test which is included in this Anxiety Disorders Toolkit (see Appendix 1). Many of these adults first experienced problems due to anxi- Whether you complete the self-test on-line or use the ety during their childhood (over 70,000 children and youth paper version, be sure to take a printed copy to a profesin British Columbia are currently suffering from at least one sional who has expertise in anxiety disorders. Ask for a full anxiety disorder). The average age of onset for an anxiety assessment, official diagnosis and consultation regarding disorder is around age 12 but many people do not develop your treatment options. If your health professional is not an anxiety disorder un- an expert in the diagnosis and treatment of anxiety disor“People from all walks of til their late teens or ders please ask them for a referral to someone who has life are affected by anxiety early adulthood years. received specialized training in this area. It is your right to disorders including some Some people will access someone who has the knowledge and the skills to of the most talented, intelexperience only provide you with effective evidence based treatments (see ligent, loveable and kind anxiety problems pages 26). A good health professional will gladly refer you people you could hope to during middle to late on to a qualified expert if a problem is outside their area of meet.” adulthood but this is expertise. less common. Anxiety Disorders are real health problems that can affect a wide range of people with very different backgrounds. How much money a person makes, the kind of work a person does, level of intelligence, and how much school a person has completed does not protect a person from developing an anxiety disorder. People from all walks of life are affected by anxiety disorders including some of the most talented, intelligent, loveable and kind people you could hope to meet.
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What do anxiety disorders all have in common?
reach out for help but can not get access to a health professional who is trained to recognize and treat anxiety disorders. Research has shown that physicians recognize an anxiety disorder in less than half of their patients who actually We often talk about “anxiety disorders” as if there was only have an anxiety disorder and of these more than two thirds one type but there are actually more than half a dozen differ-will receive an incorrect anxiety disorder diagnosis (e.g., dient types of anxiety disorders. The anxiety disorders share agnosing social anxiety disorder or depression when the permany common features and more than half of the people son is actually suffering from generalized anxiety disorder, with an anxiety disorder have more than one anxiety disor- etc). der. These people are not necessarily more ill but happen to As of 2003 most British Columbians with anxiety disorhave symptoms that fit the criteria for more than one anxi- ders do not have access to evidence based treatments other ety disorder. than medications due to shortages in trained experts and a The first step in effectively managing an anxiety disorderlow number of programs provided by the Regional Health is to identify which anxiety disorder(s) you have. The main Authorities. types of anxiety disorders that can be diagnosed are listed • For more information about effective treatment programs below: see page 24. panic disorder .................................................. see page 13 • For a full report on future plans and needs for anxiety agoraphobia ..................................................... see page 15 disorder resources see the Provincial Anxiety Disorders obsessive compulsive disorder ........................ see page 16 Strategy Report at wwwanxietybc.com . . social anxiety disorder ..................................... see page 18 generalized anxiety disorder ........................... see page 19 post-traumatic stress disorder .......................... see page 21 specific phobias ............................................... see page 22 Despite their differences, there are many similarities and common features across the anxiety disorders including excessive symptoms of anxiety (emotions, behaviours, thoughts, and bodily reactions) (see page 6).
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Fear, dread, and trying to feel safe Many people with an anxiety disorder also experience anticipatory anxiety. Anticipatory anxiety is when a person feels anxiety, fear or dread when thinking about an upcoming feared situation or experience (e.g., feeling anxiety when waiting in the pre-boarding area before having to get on a plane). Many people suffering from an anxiety disorder use “safety behaviours” to feel less anxious and safe from danger (see page 35 for more information). Vulnerability to substance use problems Individuals with an anxiety disorder can be more vulnerable to problems with substance use. Individuals most at risk are those who use alcohol or drugs to self-medicate their symptoms (e.g., using alcohol to feel less socially anxious when attending a work party). Benzodiazapines (e.g., Xanax, Ativan) are sometimes prescribed for people with anxiety disorders (especially those experiencing panic attacks). Unfortunately many people are unaware that benzodiazepines can be addictive. Likewise, some people with an anxiety disorder take over-the-counter or prescription medication for sleeping problems. Unfortunately these medications can also be addictive. For more information and helpful resources for substance use problems see the Kaiser Foundation website (wwwkaiserfoundation.ca . ). Barriers to diagnosis and treatment It is common for people suffering from an anxiety disorder to go for years without a proper diagnosis. Sometimes this is because the anxiety and avoidance behaviours makes it difficult for the affected person to get help (e.g., extreme fear of leaving the house, traveling to a health care appointment, or interacting with a health professional). Other times people 10
How are anxiety disorders different from depression?
Resources for depression
For a Depression Self-Management Toolkit created by BC experts see www.mheccu.ubc.ca/publications/scdp/ patientguide.pdf. Anxiety and depression are both negative emotional states The BC Partners for Mental Health and Addictions Inforthat can be accompanied by a range of negative body reac- mation Depression Toolkit and and Primer fact sheet on detions, thoughts and behaviours. Although the symptoms of pression are available on our website at anxiety and depression can overlap (e.g., fatigue, difficulty www.heretohelp.bc.ca concentrating, changes in appetite, etc) there are also some For more information about depression and how to effecimportant differences. Anxiety disorders and major depres- tively self-manage depression please see: sion are not the same thing. The main characteristics of anxiety disorders are excessive anxiety, fear, and avoidance of Websites the things that trigger anxiety or fear (see page 6 for a list of • Canadian Mental Health Association – BC Division common anxiety symptoms). The main characteristics of www.cmha-bc.org major depression are excessive sadness or emptiness and • Mood Disorders Association of BC www.mdabc.ca lack of motivation or pleasure in our usual activities. • Mood Disorders Society of Canada
www.mooddisorderscanada.ca The most common symptoms of depression can include: • Canadian Psychological Association Depression Fact • negative mood (feeling sad, “blue”, empty, irritable) Sheets www.cpa.ca/factsheets/depression.htm • lack of motivation or interest in doing our usual activities • American Psychological Association Depression Inforor pleasurable things mation www.apa.org/psychnet/depression/html • notable decreases or increases in appetite/weight/energy levels Books • problems with sleep (e.g., sleeping too much, difficulty Burns, D.D. (1999). The feeling good handbook, Revised Edifalling or staying asleep) tion. New York: Plume. • feeling worthless, guilt or self-blame Burns, D.D. (1999). Feeling Good: The new mood therapy. New • problems with thinking, concentrating or making deci- York: Quill. sions Greenberger, D., & Padesky, C.A. (1995). Mind over mood: • problems with sexual desire, sexual arousal or sexual per-Change how you feel by changing the way you think. New formance York: Guilford Press. • thoughts about death, harm to self or others, or suicidal Luciani, J. (2001). Self-coaching: How to heal anxiety and dethoughts and urges pression. John Wiley & Sons. You are not alone if you have experienced problems with ARE YOU EXPERIENCING THOUGHTS anxiety and depression. Approximately 50% of people with an anxiety disorder have also experienced depression. These ABOUT HARMING YOURSELF OR rates are not surprising when you consider how demoralizSOMEONE ELSE? ing and depressing it can be to live with a poorly managed or If so, please go immediately to your personal physician or untreated anxiety disorder. the emergency room at the nearest hospital. Tell a health There are a number of ways in which anxiety disorders can be professional the full details of what you are experiencing so association with increased risk of depression. Anxiety disorders: that they can help you. If possible please tell a trusted per• Cause negative thoughts and other difficult symptoms that son how you are feeling and ask them to stay with you until lower our mood and lead us to feel hopeless about ouryou are safe and have the resources you need. selves, the world and our future For 24 hour support during a crisis please see the emer• Lead to avoidance and isolation. Most of us will become gency page near the front of every phone book for the teledepressed if we are not actively involved with other people phone number to call in your home community. or enjoyable activities. Write the number down if you think you might need it • Puts strains on our personal and work place relationships. in the future and carry it with you in a safe place such as This stress and any associated conflicts can also increase your wallet or purse. our risk for depression. • Share common biological pathways with depression that when activated can lead to symptoms of both. This shared pathway may help explain why certain anti-depressants that influence specific neurotransmitters in our brain have been found to be an effective treatment for both anxiety disorders and depression (see page 11). Fortunately, depression associated with anxiety disorders often goes away or reduces significantly when the person gets proper treatment for the anxiety disorder. Sometimes a person may be too depressed to actively participate in a cognitive behavioural treatment program for anxiety disorders and the depression will need to be treated first. 11
How are anxiety disorders different from stress?
What are risk factors for anxiety disorders?
A very common myth is that anxiety disorders are the same Many people wonder why there are parents with an anxiety thing as problems with stress. One of the reasons for the disorder who have children who are free from anxiety probconfusion between stress and anxiety disorders is because lems or symptoms. Likewise, many children with an anxiety many symptoms of stress are also symptoms of anxiety. disorder have parents or relatives who are anxiety free. How Shared symptoms of anxiety and stress can include: can this be? The development of an anxiety disorder usually • Physical symptoms (e.g.., rapid heart rate, muscle tension,results from a complex combination of a large number of upset stomach) cognitive symptoms (e.g., distressing factors including our previous experiences, our beliefs, and thoughts and difficulty concentrating) our environment – not just genetic and biological factors. • Behaviours (e.g., urge to escape the situation, urge to drink However most research studies tend to focus upon investior use drugs) gating only one factor at a time. Try to keep this in mind the • Emotional symptoms (e.g., feeling upset, irritable or numb) next time you hear about any kind of research that has idenDuring times of stress most of us will experience at least tified a risk factor for anxiety disorders – the odds are it is some of these symptoms. An anxiety disorder is only consid- only one factor among many. ered if the anxiety symptoms are excessive and the symptoms do not resolve when the stress is over. It is important to Genetic predisposition note that many people with an anxiety disorder experience To date there has been substantial research in the area of increases in their symptoms when they are coping with stress.genetics and mental health, including anxiety disorders. ReHowever, despite the connections between anxiety and stresssearchers have attempted to locate specific genetic markers please keep in mind that stress is not the same thing as an that are associated with the occurrence of specific disorders anxiety disorder. This is one reason why stress management (e.g., panic disorder). From these types of studies we know techniques alone are not typically an effective treatment for that the tendency to feel anxiety or to have an anxiety disoranxiety disorders. That said, stress management can be an der does run in families. What this means is that if you do important component of effective self-management for anxi- suffer from an anxiety disorder there is a higher chance (comety disorders. pared to someone who does not suffer from an anxiety disFor the BCPMHAI primer fact sheets on stress, managing order) that other members of your family (e.g., child, sibling, mental health and other topics please see our website at parent, cousin, etc.) will also experience anxiety. We think of wwwheretohelp.bc.ca. . it as a vulnerability to developing anxiety. However, we have The BCPMHAI plans to release a new mental health tool also learned that even if one family member experiences kit in the Spring of 2004 that will provide general informa- anxiety problems it is not a given that other family members tion about positive mental health and wellness issues. Included will also have the same problems (in regards to the type of are tips on self-care, how to live a healthier lifestyle, strate- anxiety or degree of symptom severity). gies to reduce stress and more. This information is relevant for all British Columbians including individuals and families An existing anxiety disorder affected by anxiety disorders. Stay tuned to the BCPMAI Having one anxiety disorder can increase the risk of a perwebsite at wwwheretohelp.bc.ca . for more deson developing another anxiety disorder. As many as 70% of tails. people with one anxiety disorder have at least one other anxiety disorder. The anxiety disorders can co-occur in a variety of combinations. For example, a person with OCD may also have panic disorder, or social phobia. A person with PTSD may also have generalized anxiety disorder and so forth. Often one of the anxiety disorders is worse than the others and will be considered the “primary diagnosis”.
Perfectionism
Higher levels of perfectionism have been associated with higher levels of anxiety and related symptoms. Perfectionistic goals for ourselves and others are typically not obtainable so they often add to the stress and suffering of a person with an anxiety disorder. If we continue to reach for perfectionistic goals (rather than standards of excellence that allow for some mistakes and flaws) we will be more likely to worry, feel anxious and engage in unhealthy ways of coping (e.g., avoiding things unless they can be done perfectly, not being able to delegate tasks to other people, spending too long on certain tasks, etc). Most of the research has focused upon the role of perfectionism in OCD or social phobia and it is considered a risk factor in the development of both these disorders. That 12
What is panic disorder?
said, many individuals who can be described as perfectionistic do not have an anxiety disorder. For more information about perfectionism, the ways in which Approximately 3 to 4 out of every 100 people will suffer from it can negatively impact mental health and strategies to over- panic disorder. The core feature of panic disorder is excessive come the costs of perfectionism see Antony, M.M., & Swinson, fear of the bodily sensations associated with a panic attack (see page 4 for a description of panic attacks). In panic disorder the R.P. (1998). When perfect isn’t good enough: Strategies for coping with perfectionism. Oakland, CA: New Harbinger Publica- panic attacks occur unexpectedly when there is no real danger, they are not the result of a medical condition, and they do not tions. reflect alcohol or drug intoxication. The onset of panic disorder can occur at any age but is most Environmental factors typically sometime between late adolescence and the mid 30s. Post traumatic stress disorder is the only anxiety disorder for which a negative life event or experience is necessary for an The rate of panic disorder is higher among women in comparianxiety disorder to develop. Most of us experience a range of son to men (ratio of approximately 2 to 1). Many people with stressful experiences throughout their life without them di- panic disorder experience their first panic attack when coping rectly causing an anxiety disorder. We do know that some with stress or when experimenting with recreational drugs such environmental factors can increase the risk of experiencing as marijuana. People with panic disorder usually fear the panic attacks problems with anxiety and for some people these problems because they are concerned that something really terrible is become a full blown anxiety disorder. For example, some happening to them: people with anxiety disorders experienced high levels of fam• What if I am dying from a heart attack, stroke or some kind ily strife and tension during their childhood. These kinds of experiences can trigger anxiety and unhealthy ways of cop- • of disease? ing that increase the risk for anxiety disorders. Some people • What if I am going crazy or losing my mind? grow up observing and learning from parents or other role • What if I lose control and do something dangerous? What if I lose control and do something embarrassing? models who are very anxious and avoidant. If a child takes on the same coping style and doesn’t have a chance to learn Many people suffering from panic disorder seek medical treatmore healthy ways of coping they may be at increased risk ment (e.g., going to the local emergency room, regular physifor anxiety problems. Other times a person may develop a cian visits or using ambulance services). Many people with panic specific fear of a person, place, or thing after seeing some- disorder go through extensive medical tests which typically fail thing really bad or frightening happening. In summary, envi- to identify any significant medical problems as the underlying ronmental factors are unlikely to be the main cause for an cause of the panic attacks. People with panic disorder often try to prevent or stop the anxiety disorder but they are often one of several aggravatpanic attacks by: ing factors. • Escaping situations that trigger anxiety or panicky feelings • Finding a place that feels safe • Being with another person or pet • Avoiding situations, experiences or things that trigger anxiety or panicky feelings • Using medications or other substances (sometimes inappropriately or excessively) Many people with panic disorder also receive a diagnosis of agoraphobia (see page 15 for more information about agoraphobia). Other problems associated with panic disorder can include using alcohol or drugs in an attempt to reduce anxiety symptoms, missing work and being on disability. Approximately 50 to 60% of individuals with panic disorder have problems with depression. For many of these individuals the depression is likely the result of living with panic disorder and its symptoms. Evidence-based treatments for panic disorder (see page 26 for more detail) • Cognitive behaviour therapy (CBT) • Serotonin reuptake inhibitors (e.g., paroxetine, fluvoxamine) • Tricyclic anti-depressants (e.g., imipramine, clomipramine) • Benzodiazapines (e.g., clonazepam, alprazolam)
Example of panic disorder with agoraphobia
Charlie is a 44 year-old married man with three teen aged sons. He has been on leave from his job as a bank teller for the past 5 months due to panic disorder and agoraphobia. His first panic attack was trigged when smoking marijuana for the first and only time during the 1970’s. He experienced rapid pounding
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heart, difficulty breathing, feelings of unreality, and tingling in (1996) Don’t panic: Taking control of anxiety Wilson, R. his fingers. During this first panic attack he experienced fear he attacks (revised edition). New York: Harper Perennial. was dying of a heart attack or stroke and he went immediately Zuercher-White, E. (1997). An end to panic: Breakthrough techniques for overcoming panic disorder, 2 nd Edition. to the emergency room at the local hospital. Since that time he has experienced approximately one panic attack each week and Oakland, CA: New Harbinger Publications. often worries about having a future panic attack. He feared that Websites his panic symptoms meant he was about to die from a heart attack or stroke even though his physician has ruled out any • Agoraphobia and Panic Foundation medical problems. Over the years he has experienced signifiwww.paniccure.com cant interference in his life due to his symptoms and fear of For on-line cognitive-behavioural self-management protriggering a panic attack. For example, he quit outdoor recre- grams that teach you how to self-manage your symptoms ational activities he previously enjoyed as a young man and he of panic disorder see the following websites: had been unable to do many things away from the home with- • www.paniccenter.net out being accompanied by another “safe” person such as his • www.anxieties.com/index.php?nic=panic wife or his brother. He also tended to avoid going back to any places he has experienced a panic attack. During the last year he See page 41 for additional resources on panic disorder. began to experience heart palpitations and chest pain during his panic attacks. He experienced a particularly intense panic attack during a staff meeting that led him to leave work that day. Since that time he had been unable to return to work due to fear of another severe panic attack. In addition he continued to avoid a number of activities or situations he has avoided for many years including exercise or physical exertion, drinking coffee or colas, movie theatres, or being home alone. He was finding himself increasingly reliant upon doing things with his wife due to fear he would be unable to get medical assistance during a panic attack. He felt very depressed about not being able to work. His physician has prescribed him some anti-anxiety medication and he only felt safe if he carried it with him at all times. Fortunately Charlie signed up for a cognitive behavioural program in his community that helps people with panic disorder get back their lives. He has been attending weekly sessions where he learns effective coping strategies he can use on a daily basis. At first Charlie was really skeptical that this program would help but his physician told him 80% of people experience benefits. Now Charlie is finding the cognitive behavioural strategies really make a difference. During the past month he has experienced fewer panic attacks using controlled breathing and less frightening ways of thinking about anxiety symptoms. He still uses his medications from time to time but much less than before. By gradually overcoming his avoidance behaviours Charlie has been able to work out at the gym and he is becoming less dependent upon his wife. He is feeling much more confident and optimistic about the future and is making arrangements with his boss about gradually returning to work in the next little while.Charlie knows he will still experience occasional periods of anxiety but now he has the skills to manage and cope much more effectively.
Resources for panic disorder Books Clum, George A. (1990). Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks. Pacific Grove, CA: Brooks/Cole. Craske, M.G., & Barlow, D.H. (2000). Mastery of Your Anxiety and Panic, 3rd edition (MAP-3): Anxiety and Panic. San Antonio, TX: The Psychological Corporation. Eldridge, G.D., & Walker, J.R. (2000). Coping with Panic Workbook. Virginia: Self-change systems, Inc. Rachman, S.J., & de Silva, P. (1996). Panic disorder: The facts. Oxford University Press.
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What is agoraphobia?
fool of herself (e.g., fall down in public). As a result she avoided the following situations: driving a car, being alone at home or The rate of agoraphobia without panic disorder is controversial away from home alone, waiting in lines, heights, planes, and as different studies have found different rates. Among the gen-baby-sitting her grandchildren when alone. For years she reeral population approximately 2 to 5 out of every 100 people quired her husband or sister to go with her when doing errands report symptoms of agoraphobia without panic disorder. How-or going shopping, which has made her very dependent and ever over 95% of people who seek treatment for agoraphobia housebound at times. She also felt frequent dread in a variety also have panic disorder. We also know that the longer some- of additional situations even when accompanied by her husone lives with panic disorder the more likely they are to eventu-band (church services, social gatherings, etc.). She often left ally develop symptoms of agoraphobia. Women are 4 times as situations in which she felt dizzy and felt like there had been likely to develop agoraphobia compared to men. many “near misses” over the years (i.e., she believed she would Agoraphobia is when a person has excessive fear of being have passed out or embarrassed herself by falling down if she in a situation in which escape may be difficult or assistance had remained in the situation). Helen would have liked a part unavailable. In these situations their main fear is experiencingtime job several times during her life but her agoraphobia presymptoms of anxiety (see page 4 for a list of symptoms) or vented her from doing so, even though the family could have incapacitating and embarrassing symptoms (e.g., loss of bowelused the extra money. Her husband has been very supportive control, feeling dizzy and falling over). These concerns can leadbut has expressed disappointment that they have been unable to significant avoidance of several types of situations: to travel during their retirement years due to her fears. The • • restaurants waiting in lines negative impact of her agoraphobia on her family has led to • • traffic jams shopping malls high levels of guilt that has compounded her suffering. • • parks isolated places Recently all this started to change and Helen is proud that • • being out of town driving situations her friends and family have noticed the improvements. For the • • elevators tunnels past few months Helen has been attending an anxiety disorder • • small crowded places buses, trains, boats support group that follows evidence based principles in their • • airplanes health care visits approach. The group leaders teach other members ways of • • hairdresser/barber movie theatres coping that have been shown to benefit people suffering from • • sports arenas being alone at home avoidance and agoraphobia. They have also given Helen some • being away from home books that cover lots of really helpful information. The leaders Some people with agoraphobia are able to enter these situa- and members of this support group helped Helen develop a tions but do so with extreme discomfort or only if someone plan of action that doesn’t feel overwhelming but helps her else goes with them. Most people with agoraphobia also have gradually work towards facing her fears and doing some of the panic disorder (see page 13 for more information on panic dis- things she has been dreaming about all her life. With the suporder). port of other group members Helen has been working on daily It is important to note that in some cultures the movement assignments starting with small challenges and gradually workof women away from the home is restricted and this is not the ing up to some more difficult tasks. Some tasks she does with same thing as agoraphobia. Interestingly, people who have to her husband, other family members or a good friend. Other leave their house for work are less likely to have agoraphobia. assignments she works on alone then reports back to the supMany people with agoraphobia experience significant interferport group about how it went. So far she has been successful at ence in their lives. For example, some people are unable to waiting in line at a small store with a good friend, watching her travel, work, complete homemaking responsibilities (e.g., get-grandchildren alone for several hours, and driving to the local ting groceries, running errands, etc.) or attend appointments supermarket with her husband in the front seat. Helen knows (e.g., doctor or dentist visits, parent/teacher interviews) there are still lots of things she needs to work on but she is so much more motivated given her recent successes. There have Evidence based treatments for agoraphobia been some difficult weeks but with the support of her family, (see page 14 for more detail) friends and support group she knows she can continue to get • Behaviour therapy (BT) her life and independence back. • Medications are not evidence based treatments for agoraphobia without panic disorder. Resources for agoraphobia Books Example of agoraphobia without panic disorder: Craske, M.G., & Barlow, D.H. (2000). Mastery of Your Helen is a 69 year-old woman who raised four children who Anxiety and Panic, 3rd edition (MAP-3): Agoraphobia. San are now adults. She lives with her husband and frequently looks Antonio, TX: The Psychological Corporation. after her grandchildren during the day. She developed agoraphobia during her early twenties. Although she has never had aWebsites full panic attack she did experience a dizzy spell when home • Agoraphobics Building Independent Lives (ABIL) alone with two of her infant children. She feared something http://www.anxietysupport.org/ bad would happen to her children if she were to pass out and • Agoraphobia and Panic Foundation be incapacitated. For over three decades she has continued to http://www.paniccure.com/Overcoming_Agoraphobia/ be extremely fearful of feeling dizzy or passing out. Her main Overcoming_Agoraphobia.htm concerns were that no one would be able to assist her if she is alone and had symptoms, that she would cause harm by pass- See page 41 for additional resources on agoraphobia. ing out (e.g., crash her car if driving) or that she would make a 15
It is very important to remember that rituals performed for cultural, religious or spiritual reasons are only considered compulsions if they are considered excessive by members of the same group, if they interfere with a person’s functioning Approximately 1 to 2 out of every 100 adults meet criteria or if they are done at inappropriate times or places. for OCD and men are just as likely as women to have this Common compulsions: anxiety disorder. OCD is most likely to begin during the early • washing or cleaning (body parts, kitchen, food, etc) teens or early adult years but approximately 1 in 4 will expe- • checking (locks, appliances, body parts, etc) rience a childhood onset. Studies have shown the average • repeating actions age of onset tends to be younger for males than females, and • counting an earlier onset of OCD is often associated with a more se- • requesting or demanding assurances from others vere form of the disorder regardless of gender. For most people• ordering or arranging the OCD develops gradually over time but some people with • hoarding or not being able to throw away things • OCD report a sudden onset of their symptoms. touching or tapping objects • mental rituals (repeating words or phrases) Without proper treatment, OCD tends to be chronic and can Obsessions worsen during times of stress. Most people with OCD have Obsessions are unwanted ideas, thoughts, images or impulses that occur over and over again and create discomfort or dis- more than one type of obsession or compulsion. Some people tress such as anxiety, guilt or shame. People with OCD typi- with OCD experience a change in the types of obsessions cally experience unwanted obsessions every day along with and compulsions they experience over the years. The intensity and frequency of obsessions and compulsions often go excessive anxiety and discomfort. up and down and are most likely to worsen when experiencCommon themes of obsessions: • fear of contamination (germs, bacteria, viruses, dirt, ing ra- life stress or symptoms of depression. Sometimes people with OCD are uncertain about whether diation, etc.) their obsessions and compulsions are excessive (e.g., some• excessive doubts about something one with OCD might recognize their checking compulsion is • need to have things in a particular order or arrangement excessive except when locking up the house each night be• unwanted aggressive/horrific thoughts or urges fore bed). It is very common for people with OCD to report a • fear of illness or disease surge in anxiety or tension when attempting to resist a com• unwanted sexual thoughts or urges pulsion. For this reason many people with OCD are only able • unwanted religious/spiritual thoughts or urges to delay their compulsions or they yield to them entirely. It is • numbers, colors, superstitions, etc. also common for people with OCD to incorporate their com• need to know things (e.g., certain facts) Most obsessions are accompanied by the fear that something pulsions into their daily routines. Sometimes loved ones becatastrophic or terrible may happen (e.g., someone will be come involved (e.g., all family members removing their shoes harmed or die). Because obsessions lead to high levels of and changing out of work clothes before entering the family anxiety and distress, many people with OCD attempt to block home to avoid triggering distress in a family member with the obsessions or distract themselves. Most people with OCD obsessions and compulsions around fear of germs and dirt). also try to feel safe by engaging in compulsive behaviours or Sometimes the desire to resist compulsions goes away, especially if the person has been coping with the OCD for a long mental rituals. time. This may be one of the reasons why an earlier age of onset is often associated with a more severe form of the disCompulsions order. Children are often unaware their symptoms are excesA compulsion is a thought or behaviour that a person uses sive and do not want to resist compulsions (which can add to over and over again to prevent or reduce anxiety, discomfort the challenges faced by parents of a child with OCD). or distress. The goal of a compulsion is not to provide pleasure or gratification. (For this reason, behaviours such as gambling, overeating or sexual acts are not considered compul- Associated problems sions even though they may feel “compulsive” to the person OCD can seriously interfere with a person’s functioning in engaging in them). Many people with OCD are aware their terms of normal routine, work, relationships, family, school, compulsions are unrealistic or excessive but they feel driven and social activities. Many people with OCD try and avoid to do them. Often the compulsions are performed in a set the objects, activities or situations that trigger obsessions and way with rules, even if the rules don’t make much sense to compulsions. The avoidance is usually directly related to the the person (e.g., washing hands exactly 10 times counting content of the obsession and often restricts the person’s acdown from 10 to 1). Compulsions can also be unrealistic in tivities. To illustrate, a person with obsessions about bacteria the way they are used to prevent a bad event from happen- may avoid touching doorknobs and money. A person with ing (e.g., deliberately telling a person “have a safe flight” ex- obsessions about harming a loved one may lock away all the actly seven times to prevent them from dying in a plane crash). knives and sharp tools. Some individuals become completely People are more likely to engage in compulsions at home or housebound and may also have serious restrictions in their when alone than when they are with friends, teachers, people activities within their own home (e.g., not entering certain they work with or even strangers. Often a person feels com- rooms in the house). Some people also experience social isopelled to repeat a compulsion if they are interrupted or until lation due to their OCD as being with others or having others in their home can trigger obsessions and compulsions (e.g., it “feels right”. a person with ordering and arranging obsessions and com-
What is obsessive-compulsive disorder (OCD)?
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pulsions may avoid having other people in their home in case ate dose of an anti-depressant shown to be effective for obsessive-compulsive disorder. At first he didn’t feel any benefits but they touch or mess up objects in the home). Many people with OCD have at least one other anxiety after about a month Cole realized his obsessions were much lower disorder, problems with depression or another type of men- than before. He has also experienced fewer symptoms of anxital health problem (e.g., eating disorder). OCD can also co- ety and an increased ability to resist the urges to engage in comoccur with Tourette’s disorder (which is typically diagnosedpulsions. During the past month Cole has noticed that when he during childhood or teen years) (see wwwanxietybc.com . forresists the urges to engage in compulsions the obsessions go more information). Among individuals with OCD approxi- away even faster. He has found it easier to concentrate and make mately 5 to 7% have Tourette’s disorder and between 20 to decisions. Now he is beginning to feel less depressed and more 30% of people with OCD report past or current tics. Approxi-confident in himself. His supervisor has noticed Cole is more mately 35 to 50% of people with Tourette’s disorder suffer productive at work so this has eased some of the work tension. The tension at home is also much lower. He reviews his sympfrom OCD. toms from time to time with his physician but the benefits have outweighed any of the occasional negative side effects he has Evidence Based Treatments for OCD experienced. Cole has started to read one of the recommended (see pages 22 for more detail): • books on OCD. From what he has read so far he will likely expeCognitive Behaviour Therapy (CBT) • rience even more benefits if he adds some cognitive-behavioural Serotonin Reuptake Inhibitors (e.g., sertraline, fluoxetine) strategies to his existing self-management program. Example of obsessive-compulsive disorder Cole is a 44 year old man who lives with his wife and their two teenage children. Cole has experienced obsessions and compul- Resources for obsessive-compulsive disorder sions around both checking and ordering/arranging for as long Books as he can remember. As a child he would place the objects in his Baer, L. (2000). Getting control: Overcoming your obsessions bedroom in groups of three and would get so upset at his siband compulsions, Revised Edition. New York, NY: Plume. lings for moving them that his parents allowed him to place a de Silva, P. & Rachman, S.J. (1998). Obsessive-Compulsive lock on his door. He would also compulsively check his schoolDisorder: The Facts. (2nd edition). Oxford. work for mistakes and this often interfered with completing ex- Foa, E.B., & Kozak, M.J. (1997). Mastery of your obsessive ams or homework. Cole was unable to finish grade 12 or attend compulsive disorder, client workbook. San Antonio, TX: university for this reason. Due to the interference of his OCD The Psychological Corporation. Cole has chosen to work for over 20 years as a maintenance Foa, E.B., & Wilson, R. (2001). Stop obsessing! How to worker at a local hospital even though he always wanted to be a overcome your obsessions and compulsions, revised pharmacist. Cole has noticed that his compulsive checking of his edition. New York: Bantam. work increases when he feels moody or when he has experi- Hyman, B.M., & Pedrick, C. (1999). The OCD workbook: enced tension or conflict with a family member. He has often Your guide to breaking free from obsessive-compulsive been reprimanded for his slow speed at work due to his obsesdisorder. Oakland, CA: New Harbinger Publications. sions about making a mistake and his compulsive checking (e.g., Penzel, F. (2000). Obsessive-Compulsive Disorders: Getting redoing a job to be sure he has completed it properly, going back well and Staying well. Oxford University Press. to a past job site to check that electrical switches are off, com- Schwartz, J.M. (1996). Brain Lock: Free yourself from Obsespleting a job very slowly in order to prevent any mistakes). Withsive-Compulsive Behavior. New York: Regan Books, out the help of his union he would have lost his job on several Harper Collins. occasions and this has created conflict with some of his co-work- Steketee, G.S. (1999). Overcoming obsessive compulsive ers. At home he experiences strong urges to arrange objects in disorder (client manual). Oakland, CA: New Harbinger set places (e.g., from smallest to largest in straight lines) and will Publications. get very upset if his wife, children or their friends touch or move Steketee, G., & White, K. (1990). When once is not enough: certain objects in the home. As a result his children rarely invite Help for obsessive compulsives. Oakland, CA: New Harfriends home and are spending increasing amounts of time away binger Publications. from the home when Cole is there. This has been very upsetting for him as he cares deeply about his children. His wife has been Websites very understanding but his symptoms have been stressful for • For an on-line cognitive-behavioural self help program her. Cole is unable to send a letter or email without spending for OCD see the following website: www.anxieties.com/ substantial time checking it for errors or comments that could index.php?nic=ocd be misinterpreted by the reader. He will often ask his wife to • For a source of high quality information and resources check these kinds of things for him even if inconvenient for her. for OCD see the following US site: Obsessive CompulRecently he took a trip with his wife to Hawaii, which was very sive Foundation (OCF): wwwocfoundation.org . stressful due to his compulsive checking of their luggage and tickets at home, the airport and the hotel. Cole feels as if his See page 41 for additional resources on OCD. OCD has interfered with his ability to reach his full potential and he wondered if he would ever be able to enjoy work or leisure activitieswithouthisobsessionsorcompulsionsgettingintheway. Cole recently began to feel optimistic about his future for the first time in a long time. His physician prescribed him a moder-
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Example of social anxiety disorder: Sandra is a 35 year old female with social phobia who lives Recent studies suggest that social anxiety disorder is the most alone. She experiences extreme fear of negative evaluation common anxiety disorder with approximately 7 to 13 out of when interacting with most people. She was extremely anxevery 100 people suffering from this disorder at some point in ious as a child and spent most of her teens alone, as it was their lifetime. Social anxiety disorder is just as likely to occur very difficult for her to be in social situations with her family in men as in women. Although the onset can occur at any or peers. Her main fear is that other people will disagree time, most people with social anxiety disorder first experiencedwith her or get angry with her. She is very concerned that problems during early childhood or their teens. interacting with other people will result in some kind of verWhen describing social anxiety disorder it is important to bal conflict that she will not be able to handle or that it will point out the difference between shyness vs. social anxiety draw the attention of other people. She has feared any type disorder. Shyness is feeling uncomfortable, anxious or tense of interpersonal conflict with other people for as long as she when talking with other people or when doing something in can remember. As a result she especially avoids conversafront of other people. Feeling shy in certain situations can be a tions that require her to express an opinion and it is difficult normal and common experience (e.g., when giving a talk in for her to watch or overhear any kind of interpersonal confront of a group of people or when going on a date with a new flict (even if on a TV show). Her anxiety is most severe when person). For some people the excessive shyness or “social anxi-she is interacting with family members or the people who ety” leads to significant problems such as social isolation/lone-live in her apartment building. Her social anxiety is very upliness, unemployment, limited educational or career achieve- setting for her and she often feels anxious for most of the ments, or avoiding important things (e.g., work related activi- day. She has been unemployed and living off her small savties, getting together with friends or family). Social anxiety ings for the past 3 months after leaving her job due to exdisorder is also associated with increased risk of substance treme anxiety when interacting with coworkers or customabuse if people try to self-medicate their symptoms (e.g., us- ers. She would love to have friends but tends to avoid people ing alcohol to feel less inhibited in social situations). once they express any kind of interest in her (e.g., asking personal questions or what she thinks about something). She has been using alcohol to try and reduce her anxiety at famMain Features People with social anxiety disorder have one thing in common: ily functions and now this has become a second problem excessivefearofembarrassment/humiliationorbeingevaluated (e.g., she feels like she is becoming dependent on using it, negativelybyotherpeople.Mostpeoplewithsocialphobiadescribe she worries excessively that family members will confront a strong fear that they might do or say the wrong thing. For ex- her about her drinking,). She wants to have a romantic relaample, “What if they think I am an idiot or a loser? What if they tionship and close relationships with friends and family, but don’t like me? What if I make them mad at me? What if I go blank she feels too tense and nervous to get close to others. She and can’t think of the right thing? What if I tremble or shake and spends much of her time thinking about everything she is they notice?” The common underlying concern is the fear that missing out on because of her fears and anxiety symptoms. otherpeoplewillrejecttheminsomewayforbeingincompetent. She is worried she will never be able to have a husband or People with social anxiety disorder often experience a variety of family of her own and is finding it harder to be optimistic physicalsymptomsofanxiety(e.g.,rapidheartbeat,sweating,blush-about her future. Sandra ended up talking to another family member about ing,tremblingorshaking,oranurgentneedtourinate)(seepage4 for more information about anxiety symptoms). Sometimes it is how she was feeling and found out that she is not the only these symptoms (and the fear that others will notice and think person is her family to have coped with severe anxiety probnegativelyofthem)thatbecomesthefocusforapersonwithsocial lems. This helped her feel more comfortable talking to her physician who prescribed her an anti-depressant shown to anxiety disorder. People with social anxiety disorder may fear only one specific be effective for symptoms of social anxiety disorder. Sandra social situation or a variety of social situations such as public speak-couldn’t believe how much better she felt after several weeks ing, eating or drinking in front of other people, writing/working/ and is starting to think she is not as shy as she thought. She playing while others are watching, making conversation, dating still feels anxious around other people but she has been seesituations, parties, joining or leaving a social situation, interacting ing a few select family members and friends more often lately. with an authority figure or having to be assertive. Because social With the support of a close friend she has also started atanxiety disorder can lead people to avoid social activities, some tending a local support group for overcoming alcohol probpeople with social anxiety disorder become socially isolated and lems. She is now learning about the connections between lonely which can be a risk factor for developing depression. her social anxiety symptoms and her urge to use alcohol to make the symptoms go away. Sandra has been visiting several websites that provide tips on healthy ways to manage Evidence Based Treatments for social anxiety social anxiety that increase her confidence and self-esteem. disorder (see pages 26 for more detail) She is also going to talk to her physician about getting a re• Cognitive behaviour therapy (CBT) ferral to a cognitive-behavioural treatment program. From • Behaviour therapy (BT) what she had read this type of program will teach her some • Serotonin reuptake inhibitors (e.g., fluvoxamine, extra skills that will make it easier to return to work and build paroxetine) up a more satisfying social life. • Monoamine oxidase inhibitors (e.g., phenelzine) • Benzodiazapines (e.g., clonazepam) Beta blockers are not an evidence based treatment for social phobia.
What is social anxiety disorder?
18
What is generalized anxiety disorder (GAD)?
Resources for social anxiety disorder Books Antony, M.M., & Swinson, R.P. (2000). The shyness and social anxiety workbook: Proven, step-by-step techniques From time to time all of us will find ourselves worrying about for overcoming your fear. Oakland, CA: New Harbinger ourselves, someone we care about or some kind of experience Publications. or event in our lives (especially if we are coping with stress). Carmin, C.N., Pollard, C.A., Flynn, T., & Markway, B.G. (1992). Dying of embarrassment: Help for social anxiety Worries typically involve fear that something bad may happen and the fear we may be unable to cope with future stressful exand phobia. New Harbinger Publications. periences. Sometimes worries can be about real problems and Hope, D.A., Heimberg, R.G., Juster, H.R. & Turk, C.L. (2000). Managing social anxiety. San Antonio, TX: The how they are going to turn out. Sometimes worries can be about future or potential problems that may never actually happen. Psychological Corporation. Markway, B.G. & Markway, G.P. 2001. Painfully Shy: How to Overcome Social Anxiety and Reclaim Your Life. Tho- Excessive worry mas Dunne Books. St. Martins Press. For people with GAD it becomes very difficult to control their Stein, M.B., & Walker, J.R. (2001). Triumph over shyness: worries even when their life is going relatively well. The frequency Conquering shyness and social anxiety. New York: and intensity of worry thoughts and images is high, and the perMcGraw-Hill. son worries about a variety of different areas rather than just one thing. Often the excessive worrying is associated with other disWebsites ruptive and uncomfortable symptoms including sleep disturbance, • For an online brochure describing painful shyness andmuscle tension, restlessness/being on edge, being easily fatigued, social anxiety see helping.apa.org/painfulshyness irritability, and difficulty concentrating. Other individuals com• For an online cognitive-behavioural self-help program plain of feeling shaky or twitchy, muscle soreness, cold clammy see www.anxieties.com/index.php?nic=sap hands, sweating, dry mouth, nausea, diarrhea, urinary frequency, • For a self-test, information about painful shyness and an exaggerated startle response, trouble swallowing or a “lump social anxiety disorder, and useful self-management in the throat”. Some people with GAD also have physical condiinformation see www.markway.com tions associated with chronic stress such as recurrent headaches • For an online article that reviews shyness, social anxiety,or irritable bowel syndrome while others struggle with substance research to date and effective treatment methods pleaseuse problems as they try to reduce the excessive worrying and see wwwshyness.com/encyclopedia.html . related symptoms with alcohol and/or drugs. Approximately 3 to 4 out of every 100 people currently meet See page 41 for additional resources on social anxiety criteria for GAD. GAD typically becomes a significant problem disorder. during the late teens or early twenties, but many people with GAD remember being anxious as children. The rates of GAD tend to be higher among the elderly, with as many as 7 out of every 100 elderly individuals suffering from symptoms. We also know that GAD seems to affect more women than men. People coping with lower socioeconomic status (e.g., lower incomes, poor housing, etc.) are also more likely to have GAD, possibly due to a higher rate of life stressors that can make a person more vulnerable to uncontrollable worry.
Worry themes
In general, people with GAD worry about the same things as people with normal levels of worry. However people with GAD often worry about the worst case scenario (e.g., “Is my husband late home from work because he has been in a terrible car accident?” “What if my boss fires me? etc). Common worry themes include: • relationships • work or school • family or friends • pets • health issues • finances • community or world affairs • being late for appointments • getting tasks completed • other daily hassles Although all of us worry from time to time, people with GAD find it difficult to control their excessive worry and it causes 19
great distress and/or interferes with how they want to Reso urclive es on worry and generalized anxiety disorder their lives. Some people with GAD have positive beliefs about Books their worrying which make it difficult to give up (e.g., worry- Copeland, M.E. (1998). The worry control workbook. New Harbinger Publications. ing helps me solve problems, worrying helps protect me from bad things, worrying helps prepare me emotionally for when White, J. (1999). Overcoming Generalized Anxiety Disorder – bad things happens, worrying motivates me, worrying makes Client Manual: A relaxation, cognitive restructuring, and exposure-based protocol for the treatment of GAD. New me a caring person). Some people with GAD have negative Harbinger Publications. beliefs about their worry (e.g., worrying could give me cancer, worrying could make me lose my mind, my worrying Websites may cause the bad thing to happen). • For an on-line cognitive-behavioural self-help program Evidence-based treatments for GAD for generalized anxiety and worry see the following (see page 26 for more detail) website: www.anxieties.com/index.php?nic=gad • Cognitive behaviour therapy (CBT) • Benzodiazepines (e.g., alprazolam, lorazepam) See page 41 for additional resources on GAD. • Buspirone • Several anti-depressants including venlafaxine, serotonin reuptake inhibitors (e.g., paroxetine) and tricyclic anti-depressants (e.g., imipramine)
Example of GAD
Donald is a 54- year old pulp and paper mill employee who lives with his wife of 30 years with whom he has three adult children and 7 grand children. Donald experienced the onset of problems with worry during his first few years of marriage when he would worry excessively about finances, his children and their futures, and his parent’s health. Since that time he worried uncontrollably about his grandchildren being harmed, saving enough for retirement, his own health and his wife’s health. Donald’s worry interfered with his ability to enjoy his life as he always felt tense and on guard. He has also turned down multiple promotions at work due to excessive worry he couldn’t handle the increased stress and responsibilities. His back and neck constantly ached from the tension. His worrying also led to long-term problems falling asleep. He had become dependent upon sleeping pills and still felt easily fatigued most days. Sometimes he experienced upsetting images about his grandchildren being injured or harmed when worrying about them. Twice in the past these images triggered a panic attack as they were so upsetting. After a bad period of worry he often felt depressed for weeks afterwards. Donald felt envious of the enjoyment other people seem to get from life and he often felt hopeless when it came to managing his worry. Donald heard a story on the news about generalized anxiety disorder and realized with I shock that this is what he might be coping with. After reviewing his symptoms with his physician he agreed to try an anti-depressant shown to be effective for generalized anxiety disorder. After several months he did experience some benefits including less intense worry, greater ability to concentrate and less fatigue. However after experiencing some improvements Donald was motivated to experience more. He got a referral to a private clinical psychologist who specializes in cognitive-behavioural treatment for anxiety disorders. Donald has learnt several important strategies including ways to tolerate uncertainty without worrying and ways to problem solve real stress that can trigger worry. He has also been able to reduce his use of sleeping pills and muscle tension by using relaxation strategies. Donald has noticed himself enjoying the moment in a way he never thought was possible in the past. He now believes that a combination of medication and cognitive-behavioural strategies will be a very effective way for him to manage his anxiety and enjoy the years to come.
20
What is post-traumatic stress disorder? (PTSD)
Main features
People with PTSD experience symptoms that can be divided into three main categories that are listed below. Re-experiencing the traumatic event: As many as 7 out of 10 people will experience a traumatic event• unwanted thoughts or images about the event that are disat some point in their lives. Traumatic events are those that tressing evoke a sense of fear, helplessness or horror due to serious • distressing dreams or nightmares about the event injury, threat of serious injury, death, threat of death or threats • acting or feeling as if the event was happening all over again to our physical integrity. The traumatic event might be directly (e.g., flashbacks) experienced by us or we may be traumatized by watching the • feeling extremely upset if something reminds you of the event event happen to someone else or finding out it has happened • experiencing a severe physical reaction when something reto someone else. There are some events that are traumatic for minds you of the event (e.g., rapid heart rate, shaking and tremmost people such as the murder of a loved one, a sexual asbling, difficulty breathing) sault, or losing one’s home in a fire. Avoidance and numbing The following are examples of different types of traumatic • trying to avoid thoughts, feelings or conversations about the event experiences: • trying to avoid people, places or activities that remind you • sexual or physical assault of the event • domestic violence or spouse abuse • being unable to recall an important part of the trauma • children who have experienced physical, sexual or verbal abuse • experiencing a drop in one’s interest or participation in activities • crime related victimization (e.g., mugging, assault, robbery, you used to enjoy shootings, home invasions) • feeling detached or cut off from other people • natural Disasters (e.g., fires, floods, hurricanes, earthquakes) • feeling “numbed out” or having trouble experiencing some emo• terrorism tions (e.g., trouble having loving feelings) • war related experiences and combat • asensethat ones ’ future wli l be shortor lmt i i ed(eg . ., won’t have anormal • serious accidents (e.g., automobile, boat, train, airplane ac-lf i e span or won’t get married or have chid l ren because of event) cidents or industrial/work accidents) Increased arousal • torture • difficulty falling asleep or staying asleep • forced confinement or imprisonment • irritability or outbursts of anger • difficulty concentrating on things Normal reactions to trauma • being excessively on guard (e.g., constantly scanning your Not everyone who experiences a trauma will go on to develop surroundings) post-traumatic stress disorder but many people experience symp-• being easily startled toms of post traumatic stress after a traumatic event. For example, studies have shown that following a trauma, most of us Prevention of PTSD will experience symptoms such as disruption in sleep, decreases In an attempt to prevent the development of PTSD many in appetite, difficulty concentrating, intrusive thoughts or memo-communities or organizations will automatically send in ries, nightmares and other common symptoms of anxiety. For mental health professionals to do a single session “debriefmost people these symptoms begin to decrease in intensity over ing” when there has been some kind of trauma. People are time. They are able to move on with their lives despite their dif- usually encouraged to talk about the traumatic event and ficult experiences with no ongoing anxiety problems. sometimes attendance at these events is compulsory. Unfor-
tunately recent evidence suggests that these single session trauma debriefings are rarely helpful and may actually inFor some people exposed to a traumatic event the symptoms do crease the risk of developing PTSD in some people. For this not decrease in intensity over time and lead to ongoing prob- reason most experts now recommend that people should not lems. Research studies show that approximately 1 to 14 out of be forced to participate in these post-trauma debriefing sesevery 100 people will experience PTSD in their lifetime. Whether sions. If post trauma symptoms do not resolve in time and or not the post-trauma symptoms lead to problems can be influ- continue to create problems then the evidence based treatenced by a variety of factors including the person’s psychological ments listed below should be considered as options. health before the trauma, the age of the survivor (both the young and the elderly may be more at risk), the degree of support from Evidence-based treatments for PTSD community or loved ones, and the presence of other stressful or (see page 26 for more detail) traumatic events. Men are exposed to a higher rate of traumatic • Cognitive behaviour therapy (CBT) events but women are more likely to meet criteria for PTSD. This • Eye movement desensitization and reprocessing could be due to a variety of factors that researchers are currently (EMDR) • exploring. For example, the specific kinds of traumas experienced Several anti-depressants including serotonin reuptake by women (e.g., more likely to be sexually assaulted than men) inhibitors (e.g., sertraline, paroxetine), monoamine may increase of the risk of women developing PTSD. Men and oxidase inhibitors (e.g., phenelzine) and tricyclic antiwomen may cope differently with anxiety or trauma. Men and depressants (e.g., imipramine) women may also differ in how willing they are to report symptoms of trauma to other people. Examples of PTSD Sharon is a 23 year-old single woman who lives with her older sister. She left university 2 years ago after being sexually assaulted 21
Risk factors
What are specific phobias?
while out on a date with a male student she met through class. Since being sexually assaulted she experienced a variety of symptoms that did not go away with time. She had unwanted memories Approximately 9 to 11 out of every 100 adults have a specific of the assault whenever she saw a man who resembled the person phobia – excessive and persistent fear of a specific object or who assaulted her. She often has nightmares about the assault and situation. Many people in the general population fear some kind of object or situation. For example, many people fear sometimes they were so distressing she was unable to fall back asleep without leaving the lights on or taking an extra sleeping pill. She snakes, spiders, heights or flying on planes. For most of us experienced several panic attacks when thinking about the assault these fears do not create ongoing distress or get in the way and avoided watching movies that may show a rape scene. She had of our lives. For people with a specific phobia, their excessive been unable to talk about the assault with her physician even thoughfear leads to significant distress and interference in their lives. Many people with a specific phobia try to avoid the object she was afraid she may have been exposed to a sexually transmitted disease. She never told any friends or family as she was scared they or situation as well as anything that reminds them of it (e.g., will not believe her or will think badly of her (even though a person thoughts, conversations, pictures, etc.). Other people with speis never to blame for a sexual assault regardless of the circumstances). cific phobia may endure coming face to face with the feared She was unable to continue attending university due to fear she object or situation with extreme dread and discomfort. A perwould see the man who assaulted her and extreme difficulties con- son is only diagnosed with a specific phobia if the fear, dread centrating on schoolwork. She no longer felt any enjoyment when or avoidance of the object or situation leads to significant with friends or family and she let all of her hobbies go (e.g., quit her interference in school, work, social or daily functioning. soccer team, didn’t feel like reading her favorite type of books any- Specific phobias can be divided up into five general categomore). She felt cut off from all of those around her and she doubted ries: whether she would ever be intimate with a man ever again. This was • situational types (e.g., bridges, elevators, flying, driving, particularly upsetting as she believes it will prevent her from having enclosed places, etc.) • a family of her own despite her strong desire to have children. When natural environment types (e.g., storms, heights, water, out in public she felt constantly on guard, especially if men were etc.) around. She found it difficult to keep a job and did not feel safe living • Blood-injection-injury types (e.g., blood, injuries, injecon her own. She had become very angry when her sister had brought tions, medical Animal/Insect types (e.g., dogs, snakes, male friends to their apartment and this was creating tension in spiders, bees, birds, cats, horses, mice, etc.) • their relationship. Other types (e.g., situations that may lead to choking, vomiting or contracting an illness, loud sounds, people in Fortunately Sharon saw a brochure at a local community cencostumes [may be specific phobia for children] or any ter about symptoms of post traumatic stress disorder. She had the other situation or object that creates a phobic response courage to call one of the support numbers listed for more inforthat is not included in the other categories). mation. Sharon eventually asked her physician for a referral to a Situational type phobias are the most commonly diagnosed, clinic that specializes in the diagnosis and treatment of anxiety disorders. The therapist she was assigned to put her at ease and followed by natural environment, blood-injection-injury, and was very gentle and kind. They worked together as a team and animal types respectively. In general, 75 to 90% of individuals with animal, natural environment, and situational types went at a gradual pace so that Sharon was not overwhelmed. Gradually Sharon has been able to face the difficult memories of what of specific phobias are women. The only exceptions are she has been through. She has also learned ways to put her life heights and blood-injection-injury phobias of which 55 to 70% back together and build up her strengths again. The memories areare women. Many people with specific phobia have more intruding less, she is less irritable with others and she is feeling than one fear within the same subtype (e.g., fear of enclosed ready to return to school even though she knows it will be challeng- places and elevators, fear of snakes and spiders, etc.). ing at first. Sharon is starting to feel safe again and day by day is doing more of the things she always enjoyed in the past. Sharon Risk factors will never forget what she went through but she now knows that Specific phobias can develop at any age including childhood. she was not to blame and life can be good again. Some people develop a specific phobia after being exposed to a
traumatic or frightening event. For example some individuals develop a driving phobia after being in a motor vehicle accident while others develop a dog phobia after being bitten by a dog. It is important to remember that most people exposed to these types of events do not tend to develop a specific phobia. Other individuals develop a specific phobia after experiencing a panic attack or observing someone else in the feared situation. For example some people fear heights after watching someone else Studiesfall from a high place while others fear water after watching someone drown or almost drown. Other times people develop a phobia after being told or instructed to fear the object or situation. For example some children may develop a phobia of an animal or insect after an adult repeatedly tells them the animal or insect is dangerous. Many people with specific phobias can trace their fears back to childhood but there are also some people with specific phobia who developed their fears as an adult (typically this occurs during early adulthood).
Resources on Post-traumatic stress disorder Books Matsakis, A. (1996). I can’t get over it: A handbook for trauma survivors, Second Edition. Oakland, CA: New Harbinger Publications. Websites • International Society for Traumatic Stress www.istss.org/resources/index.htm • PTSD Alliance www.ptsdalliance.org • BC Institute against Family Violence www.bcifv.org See page 41 for additional resources on PTSD. 22
the agreed upon times. This unpredictable behaviour was leadPeople with specific phobias sometimes fear harm due to ing to many arguments with his concerned parents and his the object or situation. For example someone with a phobia doctor was very worried about his health if he was unable to of flying may fear dying as a result of a plane crash. Some- comply with his insulin program. Joe was aware he was putone with a bee phobia may fear dying from a bee sting. Some- ting his health in serious danger, which only added to his one with a height phobia may fear falling over the edge of suffering. Recently he had felt very depressed and hopeless the building and being injured or killed. Other individuals about the future because of these problems. Everything changed when Joe received a referral to a lowith specific phobias may fear losing control. For example a person with a bridge phobia may fear losing control of their cal mental health team who has staff with specialized traincar and crashing. Others with specific phobia fear panicking. ing in cognitive behavioural treatment for specific phobias. For example someone with a phobia of water may fear hav- With the help of the diabetes clinic nursing staff his therapist ing a panic attack if they enter deep water. Fear of fainting is has set up a gradual plan that allows Joe to build up his toleralso a common fear among those with specific phobias. Many ance for having his insulin injections. They started with getpeople with specific phobia of blood, injections or injuries ting Joe used to looking at the needle, filling up the needle fear passing out if they see or hear about any of these three with the insulin and then watching videos of other people getting insulin injections. With lots of practice these situathings. tions no longer cause extreme anxiety. Joe still requires someone else to give him his injections but he is has been much Associated problems more cooperative and doesn’t feel panicky anymore. This Most people with specific phobias experience a restricted has relieved a huge amount of daily stress for him and his lifestyle or limitations in their functioning as a result of their family. He plans to work up to watching himself getting the excessive fear and related symptoms. For example, having a injections (on video first and then in real life). Eventually he flying phobia can interfere with taking certain jobs, taking will practice giving himself his own injections. His parents certain vacations, or visiting out of town family and friends. are really proud of him as it takes a lot of courage to cope Other times the specific phobia may actually lead to a health with an illness like diabetes in combination with a phobia of threat (e.g., avoiding necessary invasive medical proceduresneedles. Joe is feeling less depressed as he feels confident he such as surgery or not being able to receive proper treatmentwill be able to live independently and do all the exciting things via injections). he has planned for his life.
Main features
Evidence based treatments for specific phobias (see page 26 for more detail) • Cognitive behaviour therapy (CBT) • No medications have been shown to be an effective treatment for specific phobias.
Resources for specific phobia Books Antony, M.M., Craske, M.G., & Barlow, D.H. (1995). Mastery of your specific phobia (client workbook). San Antonio, TX: The Psychological Corporation; Graywind Publications: Boulder, CO. Example of specific phobia: Brown, D. (1996). Flying without fear. Oakland, CA: New Joe is a 21 year-old college student who lives with his parents Harbinger Publications. and younger sister. During the past year he was diagnosed with diabetes and his management program includes daily Websites insulin injections. He has always been uncomfortable with • For an on-line cognitive-behavioural self-help program seeing injections or blood for as long as he can remember. for overcoming fear of flying see the following As a child he passed out once when having his blood drawn website:www.anxieties.com/index.php?nic=flying for standard medical tests. Since that time he avoided view- • For an on-line cognitive-behavioural self-help program ing or thinking about anything related to injections, blood or for overcoming other specific phobias see the following medical procedures as they make him feel anxious, nauseous website: www.anxieties.com/index.php?nic=phobias and dizzy. He also experienced a limited symptom panic attack during his first year of college when he had to walk by a See page 41 for additional resources on specific phobias. blood donor clinic being conducted in the main foyer of the college building. Since his diabetes diagnosis he had been unable to give himself his own injections or complete the training for self-injecting with the nurse at the local diabetes centre. His mother and father had to make special arrangements so that one of them is able to administer his insulin injections and this created problems for them at their places of employment. Joe had been unable to watch anyone give him the injections (he always looked away), he felt extremely anxious leading up to his scheduled injection times, and it sometimes took over an hour for him to allow them to give him the injection. Joe was often exhausted and upset for hours after an injection and this interfered with his ability to attend classes and study. Sometimes he was unable to allow his parents to give the injection or he did not show up at home at 23
Why should I consider getting treatment?
What should I tell my health professional?
A) Most people are unable to effectively self-manage their anxiety Research has shown that only one third of the people with an anxiety disorder have seen a health professional regarddisorder until they receive some form of effective treatment. There ing their anxiety problems and the majority of these people are many costs to untreated or poorly managed anxiety disorders: • Increased risk of depression, substance use or suicide do not end up receiving any treatment. Research also sug• Increased and excessive use of health care services (e.g., diag- gests that two thirds of people with an anxiety disorder may nostic tests, ambulance services, and visits to physicians, spe- not have received a correct diagnosis. The purpose of the cialists, or hospital emergency rooms) following information is to help you increase the probability • Increased risk of disability status (anxiety disorders are the sec-of getting a proper assessment, diagnosis and treatment plan. ond highest source of disability among people with mental health conditions after depression) Review all of your symptoms B) Why suffer needlessly when there are treatments that work see Many people with an anxiety disorder will focus on their body page26.Effectivetreatmenthelpspeoplelowertheirsymptoms,im- symptoms of anxiety when discussing their anxiety probprovetheirself-esteemandgetbacktoenjoyingtheirlivesagain.Herelems with their physician (e.g., “My heart seems to be beataresomepersonaltestimonialsfromrealpeoplewhohavebenefited ing too fast”, “I am having difficulty breathing”, “I have been from receiving evidence based treatments for anxiety disorders: feeling dizzy and nauseous” etc). These symptoms can be • “It’s been more than 2 years since my last panic attack…. Last especially frightening and uncomfortable so it is no wonder year I moved into my own apartment… I’ve even traveled on body symptoms are often the main thing we focus on telling my own again…. And I’m not afraid of my own heartbeat… our health professional. Unfortunately we know that the odds I’ve come to appreciate the power our brains have over our of your physician correctly identifying your anxiety disorder bodies, and the greater power our spirit has over both… I’ve decreases if you start by telling them about these symptoms. come to accept that I was suffering from panic attacks and not To increase the odds of getting a proper diagnosis be sure to dying from some mysterious disease.” also tell your physician about your other symptoms of anxi• “I now have the strategies to combat the negative thoughts… I ety (emotions, thoughts, and behaviours). We recommend am able to tackle my daily life and not avoid things…. I have you fill out the checklist provided on the following page and become more focused at work and am working more efficiently/take it with you to your physician or health professional. Other important things to mention to your physician or effectively… I am doing more with family and friends…I feel healthier and have not seen my doctor since I have started (cog- health professional include any stressful events or major nitive behavioural program)… Nor have I called in sick to work.”changes in your life that have happened recently. Also tell • “After all these years of not knowing what was wrong with me them about any family history of mental health or substance not only did I learn what it is (this horrible thing in my mind was use problems. The BC Partners for Mental Health and Addictions Inforan anxiety disorder called Obsessive Compulsive Disorder) but I became more aware of the thinking patterns that get me mation (BCPMHAI) have a Mental Illness Toolkit available on in trouble and I was taught the tools to cope. I am slowly learn- our website at www.heretohelp.bc.ca. This toolkit also contains ing that everyone has horrible scary thoughts sometimes and useful tips on reviewing your symptoms and on speaking that I’m just like everyone else. I am becoming more confident to your mental health care professional. to take risks. My mind is clearer, I’m much less stressed, and I’m able to enjoy life without constantly having intrusions running through my head.” • “I had been reluctant to try medications... it is not like it is instant happiness ut makes you want to live like a normal person, accomplish things for myself and set goals for the future.”
Tips for talking to your doctor
Theaveragepatientasksonlytwoquestionsduringanentiremedical symptoms.Sometimesitcanhelptobringafriendorrelativealong visitlastinganaverageof15minutes.However,studiesdemonstrate forsupportandtohelpdescribeyourbehaviourandsymptomsif you’re unable to. thatpatientswhoareactivelyinvolvedindecision-makingaremore satisfied,haveabetterqualityoflifeandhavebetterhealthoutcomes. • Participate — Discuss with your doctor the different ways of hanSincemostpeople’streatmentpathforamentaldisorderbeginsinthe dling your health problems. Make sure you understand the positive and negative features about each choice. Ask lots of questions. familydoctor’soffice,belowaresometipsforempoweringyourself and starting a conversation about disabling anxiety in your life: • Agree — Be sure you and your doctor agree on a treatment plan you can live with. • Plan—Thinkaboutwhatyouwanttotellyourdoctororlearnfrom yourdoctortoday.Onceyouhavealist,numberthemostimportant • Repeat — Tell your doctor what you think you will need to do to take care of the problem. things. The BC Mental Health Information Line can also give you a list of • Report — When you see the doctor, tell your doctor what you want possibleplacesforreferralthatyoucouldsuggesttoyourdoctor.Ifyou to talk about during your visit. • ExchangeInformation—Makesureyoutellthedoctoraboutwhat’swant to find a new family doctor, the College of Physicans and Surwrong. Printing out an online screening tool (e.g., geonsofBCcanprovideyouwithalistofdoctorsacceptingpatientsin wwwfreedomfromfear.org), . orbringingadiaryyoumayhavebeenyour area. keepingcanhelp.MakesuretoincludebothphysicalandemotionalSource: Bayer Institute P.R.E.P.A.R.E Patient Education Program 24
NOTES: My anxiety symptoms checklist Check off any symptoms that you have been experiencing for several weeks or more. Only include symptoms that are excessive or cause significant disruption or interference on a regular basis. Review with a health professional trained in the diagnosis and treatment of anxiety disorders. ! Feeling anxious, fearful, scared, tense, worried, etc. ! Rapid heart, heart palpitations, pounding heart ! Sweating ! Trembling or shaking ! Shortness of breath or smothering sensations ! Dry mouth or feeling of choking ! Chest pain or discomfort ! Nausea, stomach distress or gastrointestinal upset ! Urge to urinate or defecate ! Cold chills or hot flushes ! Dizziness, unsteady feelings, lightheadedness, or faintness ! Feelings of unreality or feeling detached from oneself ! Numbing or tingling sensations ! Visual changes (e.g., light seems too bright, spots, etc.) ! Blushing or red blotchy skin (especially around face) ! Muscle tension, aches, twitching, weakness or heaviness ! Thoughts or images of something bad happening to self (dying, not being able to cope, being responsible for something terrible happening, embarrassing ourselves, etc) ! Thoughts or images of something bad happening to someone else (family member dying, a child being harmed, spouse having an accident, etc) ! Thoughts or images of something else bad happening (house burning down, personal possession being stolen, terrorism attack, etc) ! Other frightening thoughts, images, urges or memories (tell your health professional as many details as you can about the content) ! Increased attention and scanning for things related to the source of danger ! Difficulty concentrating on things not related to the source of danger ! Difficulty making decisions about other things ! Frightening dreams or nightmares ! Avoidance of the feared situation, experience, place or people ! Needing to escape or leave the feared situation, experience, place or people ! Needing to be with a person or pet who makes me feel safe ! Getting reassurance from others ! Telling myself reassuring things (e.g., “It will be ok”) ! Needing to find a safe place to go to ! Scanning the situation for signs of danger ! Trying to distract myself ! Self-medicating the symptoms with drugs, alcohol or food ! Sleeping or napping so I don’t have to think about it ! Excessive checking or cleaning ! Other compulsive behaviours or mental rituals ! Other symptoms or problems associated with my anxiety (write down in the notes section on the side)
25
What are effective treatments for anxiety disorders?
•
One of the strongest reasons for us to feel optimistic about anxiety disorders is that we actually have effective treatments that have been shown to work – they allow people to better manage their anxiety problems so they can lead fulfilling and productive lives. Two basic types of treatments have been shown to work: • 1) medications and 2) cognitive behavioural therapy. We call these “evidence-based” treatments because the results of the studies (i.e., “the evidence”) show that they work very effectively. Evidence based treatments are endorsed and recommended by the Anxiety Disorders Association of BC (ADABC) and the BCPMHAI. Be sure to ask your health professional for access to an evidence based treatment if you have been • diagnosed with an anxiety disorder.
Medications
also interact with alcohol, other medications and drugs. Beta blockers Examples include propranolol (Inderal), nadolol (Corgard), and atenolol (Tenormin). Beta blockers are primarily used to reduce the physiological symptoms associated with anxiety (e.g., heart palpitations, excessive sweating, excessive trembling or shaking, etc). They work by reducing blood pressure and slowing the heart beat. Monoamine Oxidase Inhibitors (MAOIs) Examples include phenelzine (Nardil) and tranylcypromine (Parnate). These medications were originally used in the treatment of depression but are also effective in treating some anxiety disorders. The MAOIs require strict dietary restrictions (e.g., no wine, cheese or foods with tyramine) and can not be taken with a large number of other medications. Other medications There are also a range of other medications that are used in the treatment of anxiety disorders such as buspirone and venlafaxine. There are also a range of newer medications that have not yet been thoroughly researched. Ask your physician or psychiatrist to review each medication option with you in detail.
Medications (pharmacological treatment of anxiety disorders) impact the symptoms of anxiety disorders at the biochemical level. A variety of medications are available that help improve symptoms presumably by influencing important neurotransmitters in the brain. Several medications have been shown to significantly lower symptoms for some people suf- Costs and coverage fering from anxiety disorders. Some of the most commonly Medication treatment is typically provided by physicians or psychiatrists. Visits to these health professionals are free unused medications are listed briefly below. der the current Medical Services Plan in BC. There is typi• Serotonin Reuptake Inhibitors (SRIs) These medications are also known as Selective Seroto- cally some cost involved in purchasing the medications as prescription coverage is typically less than 100% on most nin Reuptake Inhibitors (SSRIs). Examples include health benefit plans. Plan G is a mental health prescription paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), fluoxetine (Prozac) and citalopram (Celexa). drug plan that provides medications for low income residents These medications were first used as anti-depressants who can not afford medications and are at risk for serious consequences such as hospitalization. For more information but are also effective in treating some anxiety disorders. about the No-Charge Psychiatric Medication Program (Plan They typically take several weeks before benefits can be observed. Common sides effects can include dry mouth,G) contact your physician or psychiatrist. For forms and more drowsiness, constipation, gastrointestinal symptoms, information contact your local mental health services center (listed in the blue pages of your telephone directory under headache and sexual dysfunction. In some people, these medications can cause a temporary increase in anxietyHealth Authorities). when they are first started. Some cautions regarding medications • Tricyclic Anti-depressants (TCAs) • Some medications work slower than others (many need to be Examples include amitriptyline (Elavil), imipramine (Tofranil), and clomipramine (Anafranil). These medications taken for several weeks before their benefits are observable). • Some people will experience temporary side effects were originally used in the treatment of depression but are also effective in treating some anxiety disorders. Like the they start a new medication treatment for an anxiety disorder. Always review any negative side effects with your SRIs, it typically take a few weeks before benefits are physician or psychiatrist. observed and common side effects include dry mouth, • Some people are unable to tolerate the unwanted side effects. drowsiness, constipation, gastrointestinal symptoms, • Some people need to try several different types of mediheadache and sexual dysfunction. The TCAs are an older cations before finding one that works for them. class of medication than the SRIs, and in some individuals • Symptoms of an anxiety disorder often return when people can cause problems with low blood pressure. stop taking medications for anxiety. • Benzodiazepines • Some people are unable to take medications due to comExamples include alprazolam (Xanax), lorazepam plicating factors (e.g., pregnant women or the elderly) or (Ativan), diazepam (Valium), and clonazepam (Rivotril). their personal beliefs. These medications work very quickly. However they are • not recommended for long-term use for anxiety disorders Some medications can be addictive or cause withdrawal as they can be addictive and lose their effectiveness over syndromes. • NEVER stop taking a prescribed medication without contime. Common side effects can include drowsiness, sulting your physician or psychiatrist. Medications must fatigue, unsteadiness, lightheadedness, and memory be gradually tapered to prevent a rapid return of sympproblems. Elderly individuals should avoid taking this toms or other unwanted side effects. class of medication when possible. Benzodiazepines can 26
What should I know about alternative or complementary treatments for anxiety Cognitive/behavioural treatments (CBT) disorders? Of the psychosocial treatments only cognitive behavioural or For more detailed information about medications for anxiety disorders including typical doses, answers to frequently asked questions and a checklist you can use to track common side effects see The Feeling Good Handbook (Revised Edition, 1999) by David D. Burns. New York: Plume, Penguin Books Ltd.
Research has shown the majority of people who have experibehavioural programs have been shown to be effective for enced anxiety attacks report using some form of alternative people coping with anxiety disorders. Cognitive/Behavioural or complementary treatments and often at the same time Treatment (“CBT”) includes a behavioural component that they are pursuing more conventional treatment. helps the person: Commonly used alternative or complementary treatments 1 decrease the patterns of behaviour that make the sympused by people with anxiety symptoms include the following: toms worse • relaxation techniques 2 increase the patterns of behaviour that make the symp• EMDR toms less severe or disappear • imagery Programs that include the cognitive component also help the • self-help groups person identify and correct any faulty beliefs or thinking pat-• hypnosis terns that make the symptoms worse • CBT programs usually involve once weekly sessions with • biofeedback herbal medicines an expert for about 8 to 20 weeks. There are also some excel- • megavitamins lent self-help books, programs and websites that provide CBT• homeopathy programs. Research studies have shown that CBT programs • naturopathy for anxiety disorders are just as effective as medications and • massage may be superior to medications in the long term. • chiropractics • osteopathy Some cautions regarding CBT….. • acupuncture • It can take time for the benefits of CBT to be observable • • Sometimes symptoms can feel like they are getting worse • yoga dietary modifications before they get better (learning to manage any type of • lifestyle diet mental health problem requires effort and can trigger some • special diet for gaining or losing weight distress which is normal and expected) • energy healing • CBT requires repeated efforts and practice before to ben• aromatherapy efit from the skills • other lifestyle intervention programs • Sometimes depression, substance use problems, life stres-• laughter sors or some other mental health problem needs to be • folk remedies addressed first before the anxiety disorder can be suc- • melatonin cessfully treated • Sometimes a person may need to combine medications Need for further research with CBT to get benefits • Some of these remedies have been in use for hundreds or Sometimes a person may need to gradually reduce their thousands of years across a variety of people and cultures. medications to benefit from CBT CBT programs for anxiety disorders are not widely available in Any treatment or remedy typically has both pros and cons – BC. Physicians, psychiatrists and most mental health profes- even when dealing with alternative or natural remedies. Unsionals are not typically trained or covered by MSP in the deliv- fortunately most alternative therapies and treatments for anxiery of CBT programs. Clinical psychologists are the most likely ety disorders have not been thoroughly researched, although group of professionals to receive training in CBT for anxiety dis- the number of good studies is gradually increasing. At this point orders but their services are not currently covered under the in time we can not currently endorse any alternative treatMSP plan unless they are seen in a hospital setting. Alternative ments as effective evidence based treatments for anxiety disoptions for accessing CBT include online programs (e.g., the cog-orders. Some of the alternative remedies look promising and nitive behavioural self-management program available at may emerge as evidence based treatment options if there is www.paniccenter.net), self-help readings and some select clin- sufficient evidence from well-conducted studies. See ics, mental health centers or community programs. Private CBTwww.cochraneconsumer.com for reviews of existing research from a psychologist is available at your own cost. Contact the examining alternative treatments for mental health problems including anxiety. For the Health Canada Directorate of NatuBritish Columbia Psychological Association Referral Service (Tel: 1-800-730-0522 or www.psychologists.bc.ca/indexpublic.htmlral ). Health Products including warnings for certain products see: www.hc-sc.gc.ca/hpfb-dgpsa/nhpd-dpsn/index.html Some Employee Assistance Programs cover visits with a clinical psychologist. Always ask to work with someone who has received specialized training in evidence based approaches to Making a treatment choice anxiety disorders. As you read through this information please keep in mind that alternative or complementary treatments are not the first recom27
mended course of treatment for anxiety disorders (see is page 26 for unlikely that exercise alone is enough for a person to overinformation about evidence based treatments for anxiety disor- come the symptoms of an anxiety disorder. That said, reguders). However you may end up considering an alternative treat- lar exercise is probably good self-care behaviour for a perment if you have failed to benefit from evidence based treatments. son with an anxiety disorder even if it only provides temporary relief in some of the symptoms (e.g., muscle tension). Herbal remedies The most common herbal remedy taken for anxiety symp- Relaxation, controlled breathing, yoga, and toms is Kava (derived from the Kava plant). A few studies meditation suggest that short-term use of Kava (1 to 24 weeks) is effec- Relaxation, yoga, meditation and other self-regulatory tive in lowering symptoms of anxiety. Kava has been associ- techniques have a positive impact on a variety of physical ated with a range of negative side effects (e.g., skin prob- symptoms (e.g., blood pressure, heart rate, etc). However lems, hair loss, etc) and can interact with other medications they have not been widely researched as a stand alone and alcohol. Unfortunately Kava has also been associated with treatment for anxiety disorders. Like exercise, these techliver toxicity which can lead to death. As a result Health niques are unlikely to be enough on their own for a person Canada has advised consumers to discontinue or avoid tak- to overcome the symptoms of an anxiety disorder. That ing any products that contain Kava. Please be aware that there said, relaxation strategies, controlled breathing and other are over 3 dozen different names for Kava (e.g., kava-kava, similar skills are often included as part of evidence based long pepper, gi, ava root, etc). For more detailed information CBT (see page 27). These techniques are unlikely to be about Kava including its various names and common side harmful if used properly and can be an effective way to effects see the following site: http://media.healthcanada.net/ reduce anxiety symptoms or preventing them from getting worse. english/protection/warnings/2002/2002_02e.htm No other herbal remedies have been shown to significantly reduce anxiety symptoms in well-conducted studies. Unless Transcranial magnetic stimulation (TMS) future evidence suggests otherwise there are no herbal rem- TMS is a relatively new neurophysiological technique first used edies that can be recommended as evidence based treatment in the mid-1980’s. TMS involves non-invasive stimulation of for anxiety disorders. the part of the brain referred to as the cerebral cortex. A Cochrane review (see www.conchraneconsumer.com) conSome general cautions regarding herbal remedies: cluded there is not enough research yet in this area so we • Make sure you talk to your physician and your pharmacistcan not recommend TMS as a treatment for anxiety disorabout any natural or herbal remedies you are taking (or ders. In fact, initial studies seem to indicate that TMS is an considering taking). Many of these alternative treatments ineffective treatment for obsessive-compulsive disorder. Unhave side effects and can interact with prescription medi-less future evidence suggests otherwise TMS is not recomcations, alcohol and other substances or drugs. mended as an evidence based treatment for anxiety disor• The quality and quantity of active ingredients in herbal ders. therapies often varies widely across different brands and preparations. Many people are also surprised to learn that a high proportion of herbal remedies are contaminated with pesticides, herbicides, or heavy metals.
EMDR EMDR (Eye Movement Desensitization and Reprocessing) is a relatively new therapy that integrates elements of a variety of psychotherapies (e.g., psychodynamic, cognitive behavioural, interpersonal, etc). EMDR aims to rapidly change unhealthy thinking patterns and reduce excessive fears. It usually includes rapid eye movements, alternating hand taps or different types of sounds which are theorized to promote more rapid and healthy processing of the information that helps maintain the anxiety disorder. EMDR has been shown to be as effective as CBT but only in the treatment of PTSD (see page 20). It is important to note that EMDR is not an evidence based treatment for any other anxiety disorders. In fact research to date suggests that EMDR is an ineffective treatment for panic disorder, agoraphobia or specific phobias. Exercise Research studies have shown that regular physical exercise and higher levels of physical fitness are associated with lower symptoms of anxiety. Exercise also seems to result in lower levels of depression and protects people from the negative effects of stress. However exercise is not currently considered an evidence based treatment for anxiety disorders. It 28
Are self-help groups useful?
What are effective ways of Self-help groups have a long-standing history and role in helping people cope with mental health problems, mental illness managing anxiety disorders?
and substance use problems. Many people find comfort in knowing they are not alone and benefit from the emotional Educating and empowering yourself ........................ pg. 29 support and practical tips that are often provided. It is im- Managing bodily symptoms ..................................... pg. 30 portant to keep in mind that some support groups are better Healthy thinking patterns ......................................... pg. 32 than others. Problematic support groups are those that do Building strengths and overcoming avoidance ......... pg. 35 not empower people and instead keep people trapped in old Relapse prevention and maintaining gains ............... pg. 36 unhealthy coping patterns that do not help make things better. Some support groups only allow a place for members to 1. Educating and empowering yourself “vent” without attempting to solve any ongoing problems. The first step in effective management of anxiety disorders is Although it is very important to feel heard and understood learning as much as we can about the specific anxiety disorder(s) by others, a group should provide more than a venue for we are suffering from. Start by reading each section in this tool kit members to voice their concerns. The best support groups that contains information relevant to you and your situation. Then are those that provide members with reliable and accurate try exploring some of the recommended books or websites. Coninformation that helps them better understand their mental sulting with a health professional who is an expert in the diagnohealth problem. A critical component is also the passing of sis and treatment of anxiety disorders is also recommended. knowledge about helpful resources and coping strategies that Getting access to evidence based treatments for anxiety disactually help a person make progress (e.g., places to get treat-orders from a trained expert can be incredibly empowering bement, effective self-management strategies, high quality cause they actually work. With the right professional and treatbooks and websites, etc). ment many people experience significant reductions in their symptoms and notable improvements in their quality of life. Sometimes your self-management program will involve cognitive-behavioural programs (see pages 26 and 27). Attending any appointments and practicing new coping strategies on a daily basis is a big part of self-management when using cognitivebehavioural therapy. Sometimes medications will be prescribed by your physician or psychiatrist. If you are taking anti-depressant medications remembering not to miss a dose can be an important component of self-management. Keep anti-depressant medications in an easy to access place and take them at the same time each day (e.g., at breakfast, before going to bed, etc). If your prescription is getting low be sure to renew it before you run out or contact your physician to decide upon the next steps. Never stop taking a medication without consulting your physician or psychiatrist to avoid problems. For more information on adjusting to the diagnosis of a mental illness (including an anxiety disorder) and general tips on developing and maintaining your own personalized self-management plan see the Mental Illness Tool Kit also produced by the BC Partners for Mental Health and Addictions Information at www.heretohelp.bc.ca.
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Tracking symptoms
We can also empower ourselves by becoming familiar with the specific things that trigger our symptoms of excessive anxiety (see page 32 for a list of common triggers and page 6 for common symptoms of anxiety). Knowing our own personal triggers and how we think, feel or behave when coping with excessive anxiety can help us decide what things we need to include in our self-management plan. This information can also be very valuable when working with a health professional as they will ask you to describe your typical triggers and symptoms. Use the tracking symptoms sheet to document any episodes of excessive anxiety (see page 30 for an example and page 31 for your own worksheet). Try to track your symptoms for one or two weeks to obtain an accurate picture of your current symptoms. Many people continue 29
to use these tracking sheets as a way of monitoringControlled how breathing well they are self-managing their symptoms. Controlled breathing involves slowly breathing in through our Each time you experience excessive anxiety ask yourself nose and then slowly breathing out through our mouth. Instructions: the following questions and write your answers in the space provided. 1 Breathe in deeply through your nose as you count slowly 1 What specific experience or situation triggered the from 1 to 4. 2 Allow the cool air to travel all the way down into your excessive anxiety? 2 What body symptoms were experienced along with the belly. Your lower stomach will gently inflate and will extend out (do not force this – it will happen naturally). excessive anxiety? 3 What thoughts were experienced along with the exces3 Breathe out through your mouth as you count slowly from sive anxiety? 1 to 4. 4 What behaviours or coping responses were used? 4 As you breath out your lower stomach will gently deflate. 5 What was the outcome? Imagine all your tension being carried away with your warm breath. Note: Try not to raise your chest and shoulders up and down 2. Managing bodily symptoms as you breathe. You can test this by placing the palm of one It is often the excessive body symptoms of anxiety (including panic attacks) that cause problems for people with anxiety disorders (seehand on your chest and the other on your lower stomach. page 6). These symptoms are not dangerous many people feel The hand on your chest should remain still while the hand on your stomach should gently move out and in as you better when they have skills to better manage them. Evidence based strategies include controlled breathing or muscle relaxation. breathe. General tips Muscle relaxation Do not wait until you are feeling really anxious to learn and Another strategy to manage bodily symptoms of anxiety is practice controlled breathing or other forms of relaxation. In- to combine controlled breathing with muscle relaxation skills. stead put aside time to master these strategies when your anxi-For easy to follow instructions for basic muscle relaxation ety levels are low. As your skills increase so will your ability to please see our BCPMHAI website. Our version takes approxiuse these same strategies when your anxiety is higher. mately 20 minutes for beginners but can be shortened down It is normal to feel a bit anxious when you first use these to about 5 minutes with practice. strategies. It can be a new, unfamiliar or even scary experience trying to let our guard down when we have been coping CAUTION: These strategies should never be used to fight or with excessive anxiety. Eventually the anxiety will pass and block anxiety symptoms, and they should not be used to diswe begin to feel the benefits of controlled breathing and relax- tract ourselves away from anxiety or an anxiety-provoking ation. situation. If you use these strategies for these purposes they It is normal to feel a bit dizzy or lightheaded when you first will be ineffective and may increase anxiety. The strategies start using these strategies as they can result in an initial burst work best if you use them to help you relax with the sympof oxygen to the brain. This is not dangerous and indicates toms as they pass in their own time while you remain in the you are successfully engaging in relaxed breathing. These skills anxiety-provoking situation. The best approach is to experitake time and practice to be effective. ment with tolerating some anxiety symptoms without using these strategies as often as possible to build up your strengths.
Example: Tracking Symptoms
Other sources for step by step relaxation skills: Thoughts Outcome • Local bookstores may carry relaxation audio tapes, CDs or DVDs. Rushedmytalk • Local community programs a bit due to the often include relaxation. What if they Felt flushed, anxiety. Was • Bourne, E.J. (2000). The Giving a talk to notice I am heart was Felt the urge to anxiety and phobia workbook, able to answer a group of 50 nervous and pounding, fel t escape from the 3rd edition. Oakland, CA: New some questions people think badly of shaky and room Harbinger Publications. but had me sweaty • Davis, M., Eshelman, E.R., & difficul ty McKay, M. (1995). The relaxconcentrating ation and stress reduction workbook, fourth edition. Felt the urge to Oakland, CA: New Harbinger What if I am Left the theatre escape the Publications Sitting in a about to pass Felt dizzy, felt to get some theatre, told my crowded movie out and can not nauseous, fel t fresh air. Didn't friend in case I theatre get out of the hard to breat he feel like I could needed their theatre in time? go back in. hel p.
Situation or Experience
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Body Symptoms
Behaviours or Coping Responses
WORKSHEET: Tracking symptoms
Each time you experience excessive anxiety ask yourself the following questions and write your answers in the spa provided. 1. 2. 3. 4. 5.
What What What What What
specific experience or situation triggered the excessive anxiety? body symptoms were experienced along with the excessive anxiety? thoughts were experienced along with the excessive anxiety? behaviours or coping responses were used? was the outcome?
Situation or experience
Thoughts
Body Symptoms
Behaviours or urges
Outcome
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3. Healthy thinking patterns
Self-managing negative thinking patterns
If we believe these ways of thinking are true, we are more Our thinking patterns and our beliefs about the world have a like to experience symptoms of anxiety (see page 6). It can very strong impact on our feelings, our behaviours, and our be helpful to figure out which of your negative thinking patbodily reactions. Studies show that 80 to 90% of us experi- terns are true, which ones are false and which ones need a ence the types of thoughts that people with anxiety disorders little bit of adjusting. For example, some people with OCD experience (see page 6). Most of us are able to dismiss these who fear getting HIV are able to reduce their feelings of anxithoughts without any ongoing problems. In comparison, people ety and avoidance of other people when they learn we can with anxiety disorders tend to experience upsetting thoughts, not catch HIV by touching doorknobs. People who fear dying images or urges on a daily basis. These thoughts do not go of a heart attack or stroke during a panic attack are often away with time and sometimes the thoughts can get distorted. reassured to learn these symptoms do not mean they are When negative thoughts become distorted they are not en- dying. If we learn that our worst fears are not supported by tirely based on the facts even though it feels like they are true. the evidence this can help us lower our symptoms of anxiety People with anxiety disorders often feel like anxious thoughts and associated problems such as the urge to avoid or escape. pop into their minds even when they don’t want to be think- For this reason, evaluating the evidence for and against negaing about them. The negative thinking patterns associated withtive thinking patterns is an important component of selfanxiety disorders can also make us feel sad and angry. management for anxiety disorders.
Negative thinking patterns
Evaluating the evidence In his 1999 book The Feeling Good Handbook, Dr. Burns identifies several common patterns of negative thinking that canThe best way to determine if a thought is true or not is to trigger or maintain negative emotions including anxiety. Weexamine “the evidence”. Like a detective we need to gather all engage in some or all of these distorted thinking patterns all the facts we have and then collect any evidence we need from time to time – whether we have an anxiety disorder or that is missing. In their 1995 book Mind Over Mood , Dr. not. Take the following survey to figure out which kinds of Greenberger and Dr. Padesky recommend asking yourself a negative thinking patterns are associated with your exces- series of questions in order evaluate negative thoughts and sive anxiety. Check off all of those that apply to you. beliefs. Questions to to ask ask (adapted from Self-test: Negative thinking patterns (adapted from Burns, 1999) Greenberger & Padesky, 1995) ! ALL OR NOTHING THINKING: You see things in black-or-white catego• Have I had any experiences that show that this ries. If a situation falls short of perfect you see it as a total failure. ! OVERGENERALIZATION: You see a single negative event, such asthought is not completely true all of the time? • If my best friend or someone I loved had a romantic rejection or a career reversal, as a never-ending this thought, what would I tell them? pattern of defeat by using words such as “always” or “never” • If my best friend or someone who loves me when you think about it. ! MENTAL FILTER: You pick out a single negative detail and dwell knew I was thinking this thought, what would they say to me? What evidence would they on it exclusively, so that your vision of all of reality becomes point out to me that would suggest that my darkened, like the drop of ink that discolors a beaker of water. ! DISCOUNTING THE POSITIVE: You reject positive experiences by thoughts were not 100% true? insisting that they “don’t count”. If you do a good job, you may • When I am not feeling this way, do I think about this type of situation any differently? How? tell yourself that it wasn’t good enough or that anyone could have done as well. Discounting the positive takes the joy out of • When I have felt this way in the past, what did I think about that helped me feel better? life and makes you feel inadequate and unrewarded. • Have I been in this type of situation before? ! JUMPING TO CONCLUSIONS: You interpret things negatively What happened? Is there anything different when there are no facts to support your conclusion. between this situation and previous ones? ! MIND READING: Without checking it out, you arbitrarily conWhat have I learned from prior experiences clude that someone is reacting negatively to you. that could help me now? ! FORTUNE-TELLING: You predict that things will turn out badly. • Are there any small things that contradict ! MAGNIFICATION: You exaggerate the importance of your problems and shortcomings, or you minimize the importance of your my thoughts that I might be discounting as not important? desirable qualities. This is also called the “binocular trick”. • ! EMOTIONAL REASONING: You assume that your negative emo- Five years from now, if I look back at this situation, will I look at it any differently? Will I tions necessarily reflect the way things really are. ! “SHOULD STATEMENTS”: You tell yourself that things should be focus on any different part of my experience? • Are there any strengths or positives in me or the way you hoped or expected them to be. ! LABELING : Labeling is an extreme form of all-or-nothing think- the situation that I am ignoring? • Am I jumping to any conclusions that are ing. Instead of saying “I made a mistake,” you attach a negative not completely justified by the facts and label to yourself. evidence? ! PERSONALIZATION AND BLAME: Personalization occurs when • Am I blaming myself for something over you hold yourself personally responsible for an event that isn’t which I do not have complete control? entirely under your control.
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Tracking Progress
Use the “Overcoming Negative Thinking Worksheet” to track your work as you answer these questions. People often find that the evidence supports more positive, healthy and empowering ways of thinking about their current situation. If you are not sure which type of thinking pattern you are dealing with just make your best guess and proceed with the next step. The important part of this process is weighing up all the evidence for and against a particular thought or belief so that you are in a stronger position to evaluate whether it is true or not.
WORKSHEET: Healthy thinking
(Example)
Use this worksheet to examine negative thoughts that upset you or hold you back from reaching your potential. 1 2 3 4 5
Write down your most distressing thought Identify any distortions in this thought (make your best guess and then move on to next step) Identify questions to challenge the thought distortion Write down answers to questions based on the evidence What do you conclude?
Type of Thoughts Distor tion(s)
Question(s) to challenge distortions
Answers
"I am a complete All or Nothing failure at (Black and white) everything in thinking my life"
What would my best friend say?Am I ignoring some positives?What has helped in the past?
I am really good at some things in my life.Just because I made a mi stake or can't do everyt hing really well doesn't mean I am a complete failure.In the past these feelings haven't lasted forever.
"This new relationship isn't going to last and I'm going to end up alone again"
They seem to like spending time wi th What does the me.They call to make plans with me.I can't Jumping to evidence suggest?Am I control how the other person feels - all I conclusions & blaming myself for can do is be myself.There are other people Fortune teller error something not under who do love and care for me even if this my control? relationship doesn't work out.
Resources for healthy thinking patterns For additional information about how to self-manage negaAntony, M.M. & Swinson, R.P. When perfect isn’t good enough: Strategies for coping with perfectionism. Oak-tive thinking patterns please see the section(s) in this toolkit that address the particular anxiety disorder(s) you are sufferland, CA: New Harbinger Publications. rd ing from. Many of the recommended self-help books and Bourne, E.J. (2000). The anxiety and phobia workbook (3 websites contain helpful strategies for self-managing the speedition). Oakland, CA: New Harbinger Publications, Inc. Burns, D.D. (1999). The Feeling Good Handbook, Revised cific types of thoughts and beliefs that can accompany panic disorder, agoraphobia, obsessive compulsive disorder, social Edition. New York: Plume. Burns, D.D. (1999). Feeling good: The new mood therapy. anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, and specific phobias. New York: Quill. Greenberger, D, & Padesky, C.A. (1995). Mind over Mood: Change how you feel by changing the way you think. New York: The Guilford Press. McKay, M. Davis, M. & Fanning, P. (1997). Thoughts and feelings: Taking control of your moods and your life. New Harbinger Publications, Inc.
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WORKSHEET: Healthy thinking Use this worksheet to examine negative thoughts that upset you or hold you back from reaching your potential. 1 2 3 4 5
Write down your most distressing thought Identify any distortions in this thought (make your best guess and then move on to next step) Identify questions to challenge the thought distortion Write down answers to the questions based on the evidence What do you conclude?
Type of Thoughts Distortion(s)
NOTES:
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Question(s) to challenge distortions
Answers
4. Building strengths: overcoming safety and avoidance behaviours
!
!
• • •
Many people with anxiety disorders feel trapped and unable • to do the things they want to do. Even basic activities in daily • living can become difficult (e.g., driving, shopping, being around • other people). Some people with anxiety disorders are unable to • leave their home or go to work due to the severe avoidance asso- • ciated with their anxiety disorder symptoms. A critical compo- • nent of recovery for a person with an anxiety disorder is building • up their strengths and decreasing safety behaviours (see page • 35) such as avoidance of the things they fear. This process is not • something that happens over night. Building strengths and over-• coming avoidance happens gradually over time with lots of prac- • tice. This process works best if we break things down into man- • ageable chunks. •
Being in a high place Insects or animals Being away from home Touching things that feel dirty Being alone Being with other people Interacting with your boss Going to a party Saying no to an unreasonable request Answering the phone Going to the movies Going to work Having things out of order or imperfect Dating Answering the phone Being without a cell phone, vomit bag, or other items that feel like they prevent anxiety. Assigning responsibility for something to someone else
STEP ONE: List triggers of anxiety and safety • behaviours Make a list of all the things you avoid doing because of anxiety, STEP TWO: Selecting a focus for the things you do to feel safe from anxiety, and anything that self-management triggers excessive anxiety. Consult your tracking symptoms Choose a few items from your list. To set yourself up for success worksheet for ideasBe sure to include the daily things you avoidchoose the LEAST anxiety provoking items first. Do not start that most other people do. Examples of common triggers: with something that feels overwhelming – better to start small • Being in moving vehicle and gradually work up to the more anxiety provoking situations. • Shopping Imagine how satisfied and proud you will feel when you are able • Going to the mall to remove something from this list. Save your initial list so that • Going to the dentist or doctor you can track your progress over time by crossing off those things • Getting an injection or medical procedure you have successfully mastered.
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STEP THREE: Developing the next steps Break down each feared item into a series of manageable chunks. See the following example to help you understand how approach this step. Example: On page 6 we told you about Mark, the computer programmer. He has broken down each item (e.g., cell phone, supermarkets, bridges) into more than one different type of task or challenge. He imagined how he would feel doing each task and rated them using the scale below. 0 1 no anxiety at all
2
3
4
5
6
7
8
9
10 extreme anxiety
MARK’S NEXT STEPS
ANXIETY RATING (0 – 10) Leaving cell phone in car when away from home alone ................................................................................................... 2.0 Leaving cell phone at home when with friends, family or coworkers ............................................................................... 4.0 Leaving cell phone at home when away from home alone ............................................................................................... 5.0 Going to supermarket during evening hours when less busy ............................................................................................ 6.0 Going to supermarket during day hours when more busy ................................................................................................ 7.0 Running up 1 flight of stairs without checking heart rate ................................................................................................. 7.0 Driving over bridge as passenger in car............................................................................................................................ 7.5 Driving over bridge with friend or family member ........................................................................................................... 8.0 Running up several flights of stairs without checking heart rate ....................................................................................... 8.0 Driving over bridge alone during the day ......................................................................................................................... 8.5 Working out at the gym for 30 minutes ............................................................................................................................ 9.0 Driving over bridge alone at night .................................................................................................................................... 9.5 Mark will begin practicing the item with the lowest rating (leaving cell phone in car when away from home) until his level of anxiety drops as close to 0/10 as possible. Some items will be mastered within days or weeks while others will take longer. When he feels comfortable with a particular item he can then proceed to the next item on the list. 35
Now it is your turn... • Brainstorm ways to break each item down into more than one manageable component (get a trusted person to help if you get stuck). For example, if you are targeting riding the bus you might end up with several items including: riding the bus one stop with a friend, riding the bus several stops with a friend, riding one stop alone, and riding several stops alone. Make sure you include lots of items that feel manageable (low to moderate ratings of anxiety). Imagine what it would be like to experience each item and rate using the following scale:
0 1 no anxiety at all
2
3
4
5
6
7
8
9
10 extreme anxiety
Using the Building Strengths form go ahead and arrange all the items from the least difficult (lower anxiety ratings) t most difficult (higher anxiety ratings). • Begin practicing the least difficult item on a daily basis. When your anxiety level has dropped to 0 or close to 0/10 then proceed to the next item. Don’t be tempted to jump ahead – best results are achieved when gradually working through all the steps in order. If you find an item is more difficult than you expected then redo the anxiety rating and move it to where it belongs in the list. When you have successfully worked through an item celebrate your success – reward yourself by doing something special! Plan your rewards in advance to increase your motivation and to give yourself something to aim for. Note: Expect to feel some anxiety and discomfort when completing each task. This powerful technique works by gradually decreasing your anxiety each time you practice until the anxiety no longer returns. It really does work and is thought by many experts to be the most critical component of effective treatment (see page 26). • After you have mastered all the items go back to your original list of safety behaviours and choose some new areas for your self-management focus. Work through developing the next steps and repeat this process to continue building strengths, decreasing safety behaviours and overcoming avoidance. Pre-existing plans for overcoming safety and avoidance behaviours have been developed for the following fears: (see Bourne, E.J. (2000). The anxiety and phobia workbook, 3 rd edition. Oakland, CA: New Harbinger Publications). • • Supermarkets Shopping in a supermarket • • Riding as a passenger in a car Driving with a partner as passenger in a car • • Driving alone Being around strangers • • Being in a crowd Heights • • Socializing with groups of people Restaurants • • Elevators Bridges • • Buses and trains Dentists and doctors • Airports and flying •
Maintain an active self-management program Just like exercise, if we stop using self-management strategies We all have our vulnerabilities. For people with an anxiety disorder their vulnerability is likely anxiety symptoms, espe- then we usually start to lose the benefits. The best way to prevent cially when coping with stress or when feeling depressed. a lapse or relapse in anxiety disorder symptoms is to actively use Many people who have received successful treatment for our self-management strategies on a daily basis (see page 41). anxiety disorders (see page 22) fear the return of their symp- • Educating and empowering self There is always new information coming out about toms. This is a normal concern and relapse prevention should anxiety disorders and effective treatment or self-managebe included in the management plan for an anxiety disorder. ment options. See pages 26 for additional resources with reliable and accurate information. Keep the facts in mind • Managing bodily symptoms • A lapse in symptoms (e.g., a few weeks of very high anxiety People who regularly use controlled breathing, muscle symptoms) does not necessarily mean you are having a full relaxation, yoga, or exercise find these skills become blown relapse of your anxiety disorder. easier to use over time. Keeping body symptoms of • Lapses are very common and typically pass with time. Reanxiety well-managed can help us better manage panic mind yourself that you typically feel better in a few days or attacks and can save valuable physical, mental and emoweeks. In the mean time focus on continuing to do the usual tional resources. These skills can also be helpful in improvthings in your life even when you are feeling anxiety. Reing sleep quality when used around bedtime. mind yourself that even when we are not at 100% we can • Healthy thinking patterns still accomplish a lot. Sometimes we need to remind ourselves of the facts in order • If the symptoms do not go away in time go ahead then make an appointment to review your concerns with a health to maintain a healthy perspective - otherwise old unhealthy patterns of thinking can sneak back into our lives and start to professional so that you can access additional treatment or create problems again. Other times new negative thinking resources if necessary. patterns are triggered and we need to evaluate them just like older negative thinking patterns we have already worked on (see page 26).
Relapse prevention and maintaining gains
36
Building Strengths My Next Steps
Anxiety Rating
NOTES:
37
•
What can family and friends do to help?
Building strengths: decreasing safety behaviours and overcoming avoidance Perhaps the most important component of relapse prevention involves continued effort into building strengths by decreasing safety behaviours and overcoming avoidance (see page 27). A person with an anxiety disorder is much better equipped Just like athletes, those people who have been training and for effective self-management if they have at least one other practicing for some time will be stronger and more effective significant person in their life to provide effective support. The key word here is “effective” support as even when we than people who have just started their program. • Continue to get ongoing experience being around feared have good intentions we can sometimes offer the wrong kind situations and triggers. The more familiar you are with of support to a person with an anxiety disorder. To help family or friends provide effective support to a person with an something the less frightening it becomes. • Try not to avoid things whenever possible as it actually anxiety disorder we have included some basic tips and strategies. If you are a person suffering from an anxiety disorder increases anxiety over time. • Always look for ways to push yourself. Don’t kid yourself we recommend that you get a trusted person to read this section and discuss the information together. If you are trythat being careful with yourself is good self-care. • Try new things, do something you have always dreamed ing to help a loved one better manage an anxiety disorder please know that you can play a critical role in helping them about or plan an adventure. This way you will learn to enjoy feeling excited about life again without feeling anxious. reach their potential and improve the quality of their life. • Be prepared for “Red Flags” Red flags are events or experiences that can sometimes What helps? increase the symptoms of an anxiety disorder. Note that both Getting educated positive and negative life events can be red flags. The first and most important step is to get educated about • Relationship problems anxiety and the particular anxiety disorder(s) that your loved • Starting a new relationship one suffers from (see pages 13-22 for detailed descriptions • Starting a new job or new school of all the anxiety disorders). Also get familiar with the differ• Other work or school stress ent types of treatment options that have been shown to work • Financial problems or gains (see page 26). If your loved one is still learning about their • Pregnancy and post-partum anxiety disorder this is also something you can do together • Parenting stressors (e.g., visit the library together, read information from books, • Health problems (self or others) brochures, or the internet together). • Feeling depressed • Getting engaged or married Talk about the issues • Getting separated or divorced It can be overwhelming to get diagnosed with an anxiety • Death of a loved one disorder. There is a lot of new information to take in and it • Death of a pet can be difficult to make decisions about what to do. Talking • Any other life events involving change openly in a non-judgmental and gentle way with your loved • Having too many responsibilities one when they need to talk can help them start to make • Exams or job interviews sense of it all. Keep in mind you will need to back off and • Sleeping problems carry on as usual when they want to focus on things other • Drinking or using drugs than anxiety. Offer to be there when they need you for emo• Any other stressful experiences tional or practical support. For example, some people with an anxiety disorder are able to attend treatment sessions if a Relapse prevention checklist loved one drives them to their appointments. Other people ! I stay informed by consulting good websites or otherwith eduan anxiety disorder are able to make huge improvecational materials about anxiety and anxiety disorders ments in overcoming avoidance behaviours if a loved one is ! I am aware of my negative thinking patterns that increase willing to go with them to some of the places they had previmy anxiety ously been avoiding. Sometimes just letting the person know ! I am actively working on my unhealthy thinking patterns that their diagnosis doesn’t change how you feel about them and developing more healthy thinking patterns based on can be the most helpful thing of all. the facts and evidence ! I actively practice skills such as controlled breathing Working or re- with health professionals laxation strategies that help reduce my body symptoms Aofgood health professional will actively involve family or friends in anxiety the treatment plan for a person suffering from an anxiety disorder. ! I am actively building my strengths by gradually overcomThis is especially true for cognitive behavioural treatment programs ing avoidance of the things I fear and decreasing safety (see page 27) as loved ones can provide encouragement and supbehaviours port that helps with various treatment components such as over! I engage in good basic self-care behaviours and stress man-avoidance behaviours. If your loved one is getting cognicoming agement tive-behavioural treatment offer to get involved but do not be offended or upset if they turn down your request. If you are able to get involved the health professional will often schedule a session with you and your loved one to review ways in which you can help.
!
!
!
38
!
Focus on the successes escape the feared situation is not usually good advice. When managing an anxiety disorder there are often bumps Telling the person to take a sick day or a leave of absence along the road (e.g., symptom flare ups, days when effective from work or school due to anxiety is also not usually good self-management strategies are not used effectively, etc). A advice. One of the most important things a support person support person can help the affected person remember that can do is encourage the person with an anxiety disorder to ups and downs are normal and to be expected. The best thing avoid as few feared things as possible and work towards to do is focus on the positives. Compliment your loved one approaching things they are currently avoiding. The best for successes including approaching things they fear, doing strategy is to recommend that the person gradually take on new things, working on more positive and healthy ways of the least feared things and move up to the most feared thinking, getting more information about the anxiety disor- things (see page 35 for more information about overcomder, use of relaxation strategies and more. Positive feedback ing avoidance and associated problems). Encourage your helps create a positive cycle as it usually increases a person’s loved one to approach things one step at a time if it seems motivation to do even more to better self-manage the anxi- like too much (e.g., why don’t we just try 5 minutes and see how it goes, etc.). ety disorder.
x
!
Factor in the anxiety disorder when appropriate Do not push too hard or too soon It is important that the anxiety disorder does not drag family Research has shown that most people can successfully and friends into unhealthy behaviour patterns that are dis- overcome their avoidance if they start with the least feared ruptive or make the anxiety disorder worse over time. That things and gradually work up to the most feared things. said, it is important that family and friends recognize that This process usually takes weeks or months of ongoing anxiety disorders are a real health problem and sometimes efforts. If a support person pushes, coaxes or forces a allowances need to be made. Ideally any allowances are part person with an anxiety disorder to face a fear before they of an effective treatment program that gradually reduces the are ready this strategy will back fire. The person with an amount of allowances that need to be made over time. Fam- anxiety disorder may experience a large flare up in their ily and friends may need to allow a little bit more time for symptoms and may be less motivated or willing to try the affected person to complete certain tasks (especially those overcoming their avoidance in the future. Do not scold or that involve approaching feared things). There may also be berate a person with an anxiety disorder when you feel things the affected person can not do or places they can not frustrated. Do not tell a person with an anxiety disorder go at this point in their recovery. Try to be patient and under- “relax!”, “calm down!”, “don’t be stupid!” or other insulting standing but know that you are not alone if you find this comments. These are not helpful and only increase the difficult and frustrating at times. Check with your commu- affected person’s anxiety while decreasing their selfnity to see if there is an existing support group for people esteem and motivation. Progress and recovery is possible with anxiety disorders and their friends or family. A listing of when managing an anxiety disorder but it is a process that BC support groups for anxiety disorders is also available at takes time – do not expect your loved one to make “overwww.anxietybc.com (contact the ADABC to add your sup- night” progress. port group to the list).
Resources for family and friends:
Reward effort not outcome Websites It is important to reward a person with an anxiety disorder for the effort they put into managing their anxiety disorder - Family/Friends Support: Supporting a Friend/Family Memeven if their attempts are unsuccessful at times. It usually ber. Anxiety Disorders Association of Manitoba (ADAM). • www.adam.mb.ca/family/familyfriends.html takes more than one attempt for us to be successful at managing the symptoms of an anxiety disorder. Expressing positive support (e.g., compliments, planning something special Kenneth V. Strong. Anxiety Disorders: The caregivers rd as a reward, etc), can help keep a person motivated to stick (Information for support people, family and friends, 3 with self-management strategies until they see changes in Edition). New York: SelectBooks, Inc. In press. To order a their symptoms as a result of their efforts. copy visit:
What doesn’t help?
•
pacificcoast.net/~kstrong/
There are many things that we can do with good intentions See page 41 for additional resources. that actually back fire and make the symptoms of an anxiety disorder worse.
not encourage avoidance x ItDocan be tempting to recommend that a person just stay
away from the things that cause them anxiety (e.g., don’t drink caffeine, stay away from crowds, don’t fly in planes, etc). Unfortunately this makes the anxiety worse in the long run and prevents us from doing the things we need and want to do. (e.g., unable to do things alone, unable to go places, etc). As a result, telling the person to avoid or 39
What are common problems that can coexist with anxiety disorders?
Where do I go to get more help?
There is currently limited choices for people affected by anxiety disorders. Available resources vary by community and There are a variety of other conditions that can occur with region. The list below includes some of the most common anxiety disorders. These co-existing problems are often contacts for treatment options in your area. Please note that referred to as “concurrent” or “comorbid” conditions. The some of the resources will be free while others will have a fee most common co-existing conditions include: for service. Be sure to ask when setting up an appointment • More than one anxiety disorder with any health professional or clinic. • • Depression or bipolar disorder Physician or medical clinics • • Substance use problems Local mental health centres • • Attention deficit hyperactivity disorder (ADHD) or The Mental Health Information Line (604-669-7600 or attention deficity disorder (ADD) 1-800-661-2121) • • Learning disabilities Psychiatrists • • Sleep disorders Psychologists (contact the British Columbia Psychologi• Tourette’s syndrome cal Association Referral Service at 604-730-0522 or 1• Trichotillomania 800-730-0522 and ask for a cognitive-behavioural • Chronic illness or health problems (e.g., Irritable Bowel therapist with expertise and training in anxiety disorSyndrome, Chronic pain, etc) ders). A person with an anxiety disorder will usually need to effec- • Registered clinical counsellors (www.bc-counsellors.org) tively manage any other comorbid conditions to effectively • Other type of health professional with expertise and manage their anxiety disorder. For example, problems with training in evidence-based approaches to anxiety sleep or depression can often aggrevate the symptoms of an disorders anxiety disorder. See your health professional for diagnosis • Outpatient clinics at local hospital (contact the outpaand treatment of any comorbid conditions. tient psychiatry or psychology department or call the main reception listed in phone book)
Resources to get help
For more information about the different types of mental health professionals and the types of services they provide please see the Mental Illness Tool Kit produced by the British Columbia Partners for Mental Health and Addictions Information (BCPHMAI). See wwwheretohelp.bc.ca . for more information. For more information about resources for anxiety disorders in your area please contact your Regional Health Authority. • Vancouver Coastal Health Authority www.vch.ca 1-866-884-0888 or 604-736-2033 • Fraser Health Authority www.fraserhealth.ca 1-877-935-5669 or 604-587-4600 • Interior Health Authority www.interiorhealth.ca 250-862-4200 • Northern Health Authortity www.northernhealth.ca 1-866-565-2999 or 250-565-2649 • Vancouver Island Health Authority www.viha.ca 1-877-370-8699 or 250-370-8699
40
What are other useful resources for coping with anxiety and anxiety disorders?
Concluding remarks
We hope that this Anxiety Disorders Tool Kit contains information that is helpful to you or your loved one. Even though we know a lot about anxiety disorders and how to effectively manage them it is surprising how many people are suffering alone and in silence. Many are unaware that the problems they are experiencing are a real health problem that can be Anxiety Disorders Association of treated or effectively managed. If you know of someone who British Columbia (ADABC) may benefit from this information please share what The ADABC is a non-profit organization dedicated to promotyou have learned. Let them know they can get their own ing the awareness of anxiety disorders and improving accesscopy of this toolkit by contacting the BCPMHAI at to evidence-based treatment in British Columbia. See the www.heretohelp.bc.ca or the ADABC at ADABC website at wwwanxietybc.com . for a wide range of www.anxietybc.com. information related to anxiety disorders.
BCPMHAI
Resources for kids and families
We acknowledge that the information and resources included BC Partners for Mental Health and Addictions Information in the Anxiety Disorders Toolkit are primarily geared towards (BCPMHAI) is currently comprised of the Anxiety Disorders adults coping with anxiety disorders. That said, a lot of the Association of BC (ADABC), Awareness and Networking information included will be relevant to kids and families afaround Disordered Eating (ANAD), the BC Schizophrenia So-fected by anxiety disorders. We do acknowledge a need for ciety (BCSS), the Canadian Mental Health Association’s BC high quality evidence based information about anxiety disorDivision (CMHA), the Kaiser Foundation (a BC addictions charder specifically targeted to the ways in which anxiety disority), the Mental Health Evaluation and Community Consulta- ders impact kids and their families. Many of the websites listed tion Unit at UBC (Mheccu), and the Mood Disorders Associa- on this page under “other useful websites” contains information of BC (MDA). Combined, the groups have more than 100 tion specific to kids with anxiety disorders. The websites listed years of service to British Columbians and regional branch below also contain evidence based information, recommended networks or linkages throughout the province. You can find books or videos, and coping tips designed specifically for chilus on the web at wwwheretohelp.bc.ca. . dren, teens, and families affected by anxiety disorders. • The Child Anxiety Network www.childanxiety.net/ Other useful websites • • American Academy of Child and Adolescent Psychiar Anxiety Disorders Association of Canada (ADAC) www.aacap.org/info_families/index.htm www.anxietycanada.ca • • National Institute of Mental Health Anxiety Disorders Association of Manitoba (ADAM) www.nimh.nih.gov/publicat/childmenu.cfm www.adam.mb.ca • • UCLA Child & Adolescent OCD and Anxiety Program Anxiety Disorders Association of Ontario (ADAO) www.npi.ucla.edu/caap www.anxietyontario.com • • Child Anxiety and Phobia Program, Florida State Unive Association/Troubles Anxieux du Québec (ATAQ) www.fiu.edu/~capp/apd.htm www.ataq.org • Anxiety Disorders Association of America (ADAA) • National Mental Health Consumers Self-Help Clearinghous www.mhselfhelp.org/chad.html www.adaa.org • Freedom from Fear (FFF) www.freedomfromfear.com • Obsessive-Compulsive Foundation • www.ocdfoundation.org Canadian Mental Health Association • the Anxiety Panic internet resource (tAPir) www.cmha.ca/english/about/index.html • www.algy.com/anxiety/children.html Canadian Mental Health Association – BC Division The Ministry of Child and Family Development (MCFD) in www.cmha-bc.org • British Columbia has developed a new Child and Youth National Institute of Mental Health Mental Health plan that seeks to address badly needed www.nimh.nih.gov/anxiety/anxietymenu.cfm • resources for kids and families affected by anxiety disorClinical Research Unit for Anxiety and Depression ders. For more information see: (CRUFAD) www.mcf.gov.bc.ca/mental_health/mental_health1.htm www.crufad.com • the Anxiety Panic internet resource (tAPir) www.algy.com/anxiety/ Multicultural resources • Cochrane Collaboration Consumer Network We also acknowledge that the information and resources included www.cochraneconsumer.com (search for topics relating in the Anxiety Disorders Tool Kit are geared towards individuals to anxiety and anxiety disorders for excellent summa- who can read, write and speak in English. There is an urgent need ries and reviews of current research) for high quality information about anxiety disorders in a variety of languages given the cultural diversity of British Columbians. For information on anxiety and anxiety disorders in Arabic, Chinese, Spanish and Vietnamese please see www.mmha.org.au/ library/brochures/anxiety/anxiety.html 41
How do I give feedback about this toolkit?
We are strongly committed to matching this tool kit to the needs of the individuals and families who will be using the information and resources. To help us improve this toolkit we welcome your comments, suggestions and feedback.
BC Partners for Mental Health and Addictions Information c/o 1200 - 1111 Melville Street Vancouver, BC V6E 3V6 email:
[email protected] web: www.heretohelp.bc.ca tel: 1-800-661-2121 fax: 604-688-3236
Did you find the information provided in this anxiety disorders toolkit useful?
Did you find the information accurate? Please identify any errors.
Did you find the information clear in terms of writing style, size and appearance of text, general presentation and content?
Were there sections in this toolkit that were perhaps not as comprehensive as they could be?
Did you find the exercises contained in this toolkit useful and effective?
Please mail or fax this document back to us or fill out our online version of this form at www.heretohelp.bc.ca, where you will find the rest of our series of toolkits and other information regarding mental health and substance use. 42
Appendix 1: Self-test for anxiety disorders If you If answered yes to the above 4 questions, and it is These questions are not meant to be diagnostic. you think you may have a problem with anxiety, contact your significantly impairing your life, you may have a specific family physician. phobia*. • The severity of anxiety occurs on a continuum. For the problem to be considered a disorder, it must be impairing Social phobia your functioning. 1. When you are in social situations are you unusually worried about being embarrassed or being evaluated negaPanic attacks tively by other people? 1. Do you experience any of the following physical sensa- 2. Do you experience anxiety nearly every time you are in a tions that are accompanied by intense fear: palpitations/ social situation or know that you will be in a social situaincreased heart rate, sweating, trembling/shaking, short- tion? You may get so anxious you may experience a panic attack. ness of breath, choking, chest pain, nausea, dizziness/ lightheadedness, derealization, fear of losing control/go-3. Do you know that your fear is unreasonably high? ing crazy, fear of dying, numbness/tingling, chills or hot 4. Do avoid social situations or if impossible to avoid it, do you tolerate them with severe amounts of anxiety? flushes. 2. Do you have at least four of these symptoms at once? 5. Does your fear and/or avoidance of social situations significantly interfere with your life? Are you quite distressed 3. Do they reach their peak within 10 minutes? about having this fear of social situations? If you answered yes to all of the above, you have likely experienced a panic attack. People have panic attacks for If you answered yes to the above 5 questions, and it is all kinds of reasons. Please continue to determine if you impairing your life, you may have social phobia*. may have an anxiety disorder. •
Panic disorder with or without agoraphobia
Obsessive-compulsive disorder
1. Do you have frequent unwanted thoughts, images, or im1. Do you experience repeated unexpected panic attacks? pulses that are difficult, if not impossible to get rid of and cause extensive anxiety (e.g., thoughts of harming some2. As a result of these attacks have you been worried about one, blasmephous thoughts/images, urge to drive car into having more attacks, worried about the consequences of oncoming traffic)? these attacks (e.g., I may embarrass myself, have a tumor, die), or have you changed your daily routine as a result of 2. Do you try to ignore, fight, or control the thoughts, images, or impulses? the attacks (e.g., stopped exercising, stopped drinking caffeine, avoiding excessive stress). If you answered yes to the above 2 questions, and it is If you answered yes to the above two questions, and it is significantly interfering with your life, you might be expesignificantly impairing your life, you might have panic dis- riencing obsessions. order without agoraphobia*. 3. Do you repeat behaviors (e.g., handwashing, checking) or 3. Do you avoid places or situations because of the fear of mental acts (e.g., counting, praying) in response to the having a panic attack and being unable to get help, being obsessions? unable to leave, or embarrassing yourself (e.g., crowds, 4. Do you do these behaviors to prevent a feared consequence? waiting in lines, being away from home alone)?
If you answered yes to the above three questions, and it is If you answered yes to question 4 and 5, you might be significantly impairing your life, you might have panic dis- experiencing compulsions. order with agoraphobia*. 5. Do you recognize that your obsessions and/or compulsions are unreasonable and/or excessive? Specific phobia 6. Do the obsessions and/or compulsions cause great dis1. Do you have unrealistic or excessive fears of objects or situations such as flying, heights, animals, water, enclosed tress, are they time-consuming (at least one hour) or significantly interfere with your life? spaces, storms, needles, and/or blood? 2. Do you always experience anxiety when confronted with the feared object or situation or know that you will be If you have obsessions and/or compulsions and you anconfronted by it? You may get so anxious, you might have swered yes to questions 5 and 6, you might have obsessive-compulsive disorder.* a panic attack. 3. Do you try to avoid the feared object or situation at all costs? 4. Does the fear and/or avoidance significantly interfere with your life? 43
Post-traumatic stress disorder
Acute stress disorder
1. Have you experience or witnessed an event where you 1. or Have you experienced or witnessed an event where you or someone else thought they might die or experience others were threatened with death or severe injury? 2. If you answered yes to number 1, did you respond with serious injury? fear, helplessness, or horror? 2. If you answered yes to #1, did you respond with extreme 3. Do you relive the event in any of the following ways? fear, helplessness, or horror (a) recurrent flashbacks while awake (it can be as if you 3. During or after the event did you experience any of the are experiencing the event again) following: (b) frequent nightmares of the event (a) numbness or detachment (c) intrusive recollections of the event – focusing on a par-(b) feeling as if you were in a daze and unaware of your ticular image or perception surroundings (d) extreme distress when you come across things that (c) feeling as if you had stepped out of your body or that remind you of the event you were separated from others (e) panic-like symptoms when experience reminders of (d) inability to recall aspects of the event 4. Do you re-experience the event in any of the following the event 4. Do you attempt to avoid thinking about the event or try toways: frequent dreams, thoughts, images, and/or flashbacks. numb yourself in any of the following ways? (a) avoid thinking, feeling, or talking about the event 5. Do you try to avoid being reminded of the event (b) avoid people, activities, or places that remind you about 6. Are you experiencing difficulty sleeping, irritability, diffithe event culty concentrating, restlessness, and/or easily startled? (c) can recall important parts of the event 7. Have the above problems significantly interfered with your (d) significantly decreased interest in activities or partici- life or stopped you from pursuing help for yourself? pating in activities 8. Has the event occurred less than one month ago (e) feeling detached from others (f) inability to experience strong emotion (except fear and If you answered yes to questions 1-8, and it is significantly anger) impairing your life, you might be experiencing acute stress (g) inability to see yourself in the future disorder.* If you answered yes to questions 1-7 but no to 5. Do you experience any of the following since you experiquestions 8, please refer to post-traumatic stress disorder. enced the traumatic event? (a) sleep problems Generalized anxiety disorder (b) anger/irritability 1. For the past 6 months (at least) do you worry about a (c) problems concentrating number of daily activities (e.g., work, home repairs, get(d) on guard or on edge ting to appointments on time)? (e) easily startled 2. Do you find the worry difficult to control? 3. When you are worrying do you experience any of the folIf you answered yes to questions 1-5, and it is significantly lowing impairing your life, you might be experiencing post-trau(a) restlessness/being on edge matic stress disorder*. (b) fatigue (c) difficulty concentrating (d) irritability (e) muscle tension (f) sleep problems 4. Does the worry significantly interfere with your life?
If you answered yes to the above 4 questions AND you are not exclusively worried about having a panic attack (see panic disorder), social ridicule (see social phobia), contamination/break-in (see obsessive-compulsive disorder), you may have generalized anxiety disorder.* Source Diagnostic and Statistical Manual of Mental Disorders – 4th Ed. American Psychiatric Association, 1997.
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